PEDS DYNAMIC QUIZZES

Correct Answer: A. Potential for sustaining abdominal trauma ** An adolescent who has mononucleosis will have lymphadenopathy and often splenomegaly, which can persist for many months. For this reason, even after the adolescent is able to maintain his usual energy level and return to school, it is important for him to avoid activities that might result in trauma to the enlarged spleen. Incorrect Answers: B. Although an adolescent who has mononucleosis might have difficulty swallowing in the early phases of the illness, after returning to school, he should not have deficient dietary intake. C. Epstein-Barr virus causes mononucleosis and is spread primarily through direct contact with the saliva of an infected individual. Casual contact during gym and recess would be no more hazardous than having the child in a classroom. D. An adolescent who has mononucleosis will not have joint inflammation.

A school nurse is assessing an adolescent who returned to school following a case of mononucleosis. The child has a note from his provider excusing him from gym class. Which of the following findings should the nurse identify as the reason for this excusal? A. Potential for sustaining abdominal trauma B. Deficient dietary intake C. Exposing peers to the illness D. Straining sore joints

Correct Answer: D. Albuterol ** The nurse should plan to administer albuterol to a child who is experiencing an acute exacerbation of asthma. This is considered a rescue medication due to its rapid onset of action. Albuterol is a beta-adrenergic agonist that promotes bronchodilation and suppresses histamine release in the lungs. Incorrect Answers: A. Zafirlukast is not considered a rescue medication, It is a leukotriene modifier that is used for asthma prophylaxis and maintenance therapy and to prevent exercise-induced bronchospasm. B. Budesonide is not considered a rescue medication. It is a glucocorticoid that is used for long-term control and prophylaxis of chronic asthma. C. Montelukast is not considered a rescue medication. It is the most commonly prescribed leukotriene modifier used for prophylaxis

A school nurse is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse plan to administer to the child? A. Zafirlukast B. Budesonide C. Montelukast D. Albuterol

Correct Answers: B. Apply pressure to the child's nose using the thumb and forefinger E. Keep the child calm ** Applying pressure continuously for 10 minutes to the nose with the thumb and forefinger helps control the bleeding. Most bleeding comes from the front portion of the nasal septum, so pressure on this area is generally effective. If bleeding persists, placing ice or a cold cloth on the bridge of the nose and inserting cotton or tissue into the nostril might help. The nurse should keep the child calm to help slow the bleeding. Agitation can raise blood pressure, which will increase the bleeding. Incorrect Answers: A. C. A child who is experiencing a nosebleed should be placed in a seated position leaning forward to decrease the risk of aspiration. D. Applying a cold cloth to the bridge of the child's nose can help slow the bleeding.

A school nurse is providing care to a child who has a nosebleed. Which of the following actions should the nurse perform? (Select all that apply.) A. Place the child in a supine position B. Apply pressure to the child's nose using the thumb and forefinger C. Have the child tilt his head back D. Apply a warm cloth to the bridge of the child's nose E. Keep the child calm

Correct Answers: A. "I should eat extra food on busy days when I am more active." C. "I should increase my intake of sugar-free fluids when I am sick." D. "I should eat a snack 30 min before my baseball games start." ** The nurse should instruct the adolescent to increase the intake of allowable foods when the level of activity is increased. Exercise lowers blood glucose levels during and after activity. Food intake should be adjusted to compensate for the release of insulin into the circulatory system and prevent episodes of hypoglycemia. The recommended increase of carbohydrates is 10 to 15 g per hour of moderate play or activity. Additionally, the nurse should instruct the adolescent to increase the intake of sugar-free fluids when sick because fluids flush out ketones to prevent dehydration. The nurse should recommend sugar-free liquids such as water, broth, and tea. The adolescent should continue with the usual intake at mealtimes and follow the recommended meal plan as much as possible.

A school nurse is providing dietary teaching for an adolescent who has type 1 diabetes mellitus. Which of the following responses by the adolescent indicates an understanding of the teaching? (Select all that apply.) A. "I should eat extra food on busy days when I am more active." B. "I should wait for 2 hr after eating before going swimming with my friends." c. "I should increase my intake of sugar-free fluids when I am sick." D. "I should eat a snack 30 min before my baseball games start." E. "I should have a 16 oz sports drink if I start feeling weak or shaky."

Correct Answer: B. The infant turns away when the nurse approaches. ** The nurse should expect an 8-month-old infant to have a heightened fear of strangers. The infant is expected to cling to her parent and turn away when approached by a stranger. Incorrect Answers: A. The nurse should expect social smiles to begin at 6 weeks of age; however, the nurse should not expect this from an 8-month-old infant upon initially entering the room due to the infant's expected fear of strangers. C. The nurse should not expect an 8-month-old infant to reach out as the nurse enters the room due to the infant's expected fear of strangers. D. Once the infant is 12 months old, the nurse should expect an alert response to strangers once again.

A nurse in a provider's office enters an examination room to assess an 8-month-old infant for the first time. Which of the following reactions by the infant should the nurse expect? A. The infant gives the nurse a social smile. B. The infant turns away when the nurse approaches. C. The infant reaches out to the nurse to be held. D. The infant is responsive and alert as the nurse comes closer.

Correct Answer: D. Sudden decrease in wheezing ** When applying the urgent versus nonurgent priority-setting framework, the nurse should consider urgent needs to be the priority because they pose a larger risk to the client. A sudden decrease in wheezing can indicate that the child is experiencing decreased air movement and should be reported to the provider. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which finding is the most urgent. A sudden decrease in wheezing (silent chest) indicates ventilatory failure and imminent respiratory arrest. Incorrect Answers: A. The nurse should report excessively prolonged expiration to the provider; however, there is a different finding the nurse should report first. B. The nurse should report increased diaphoresis to the provider; however, there is a different finding the nurse should report first.

A nurse in an emergency department is assessing a school-aged child who is experiencing an acute asthma exacerbation. Which of the following findings is the priority for the nurse to report to the provider? A. Excessively prolonged expiration B. Increased diaphoresis C. Increased production of frothy sputum D. Sudden decrease in wheezing

Correct Answer: C. Nasal flaring ** Acute laryngotracheobronchitis (croup) causes dyspnea and swelling of the upper airway. Indications of impending airway instruction include tachycardia, tachypnea, increasing restlessness, flaring nares, and intercostal retractions. Incorrect Answers: A. Tachycardia, not bradycardia, is an indication of impending airway obstruction. B. Tachypnea, not bradypnea, is an indication of impending airway obstruction. D. A barking cough is a classic manifestation of acute laryngotracheobronchitis; however, it is not an indication of impending airway obstruction.

A nurse in an emergency department is assessing an infant who has laryngotracheobronchitis. Which of the following findings should the nurse report as indication of impending airway obstruction? A. Bradycardia B. Respiratory depression C. Nasal flaring D. Barking cough

Correct Answers: A. Identify how much cleaner was in the bottle D. Insert an IV for morphine administration E. Apply a pulse oximeter ** The nurse should ask the parent or guardian about the size of the container, its contents prior to ingestion, and its contents remaining following ingestion. This information provides an estimate of the amount of cleaner the child ingested and can assist the provider in directing treatment. A child who ingests a corrosive agent is likely to have intense pain due to burns in the gastrointestinal system. The nurse should administer morphine as prescribed via IV to provide pain relief. The child is also at risk for airway occlusion due to edema following ingestion of a corrosive agent. Monitoring the child's oxygen saturation level will help the nurse recognize if the child's airway is becoming obscured, Incorrect Answers: A. A child who has asthma should have a pulse oximetry reading of 90% or greater; therefore, this is not the nurse's priority finding. B. A child with nephrotic syndrome typically has moderate to large amounts of protein in the urine; therefore, this is not the nurse's priority finding.

A nurse in an emergency department is assisting with the care of a 4-year-old child who ingested toilet bowl cleaner. The child has hemoptysis, is crying, and states, "It burns." Which of the following actions should the nurse perform? (Select all that apply.) A. Identify how much cleaner was in the bottle B. Administer activated charcoal C. Perform immediate gastric lavage D. Insert an IV for morphine administration E. Apply a pulse oximeter

Correct Answer: D. Determine the child's breathing pattern ** The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Hence, determining the child's breathing pattern is the first action the nurse should take. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Incorrect Answers: A. The nurse should cover the child's wounds with a clean, dry cloth; however, there is a different action the nurse should take first. B. The nurse should establish IV access for the child using a large-bore catheter; however, there is a different action the nurse should takefirst. C. The nurse should provide reassurance to the child's parents; however, there is a different action the nurse should take first.

A nurse in an emergency department is caring for a 4-year-old child who has burns to the neck and face following a house fire. Which of the following should the nurse take first? A. Cover the child's wounds with a clean, dry cloth B. Establish Iv access with a large-bore catheter C. Provide reassurance to the child's parents D. Determine the child's breathing pattern

Correct Answer: C. Drooling ** Epiglottitis is a disorder caused by an inflammation of the epiglottis. It results in rapid swelling of the epiglottis, which can obstruct breathing. Drooling is an expected finding due to the toddler's inability to swallow saliva. Incorrect Answers: A. A toddler who has epiglottitis is restless and appears anxious rather than lethargic. B. A toddler who has epiglottitis has an absence of spontaneous coughing due to inflammation of the epiglottis. D. Hoarseness would be present in a toddler who has acute spasmodic laryngitis rather than epiglottitis.

A nurse in an emergency department is caring for a toddler who is in acute respiratory distress. Which of the following findings should alert the nurse to the possibility of epiglottitis? A. Lethargy B. Spontaneous coughing C. Drooling D. Hoarseness

Correct Answer: D. Adult tetanus booster (Td) ** Td is recommended for wound prophylaxis in children ages 7 years and older. Td is also recommended every 10 years after 18 years of age. Incorrect Answers: A. DTAP is used to provide immunity against diphtheria, tetanus, and pertussis in infants and children under the age of 7 years. DTAP is not recommended for wound prophylaxis. B. TIG and DT may be given concurrently for wound prophylaxis, but the nurse should administer these immunizations separately using different muscles. DT is given as wound prophylaxis to children under the age of 7 years. C. Tdap is given to adults and adolescents who have completed the initial DTAP immunization series but have not yet received an adult tetanus booster (Td). The minimum age for TdaP is 10 years; however, children between the ages of 7 and 10 years who have not received all recommended doses of DTAP should be given a dose of Tdap. Tdap is not recommended for wound prophylaxis.

A nurse in an emergency department is caring for an 8-year old who is up-to-date with current immunization recommendations and has a deep puncture injury. Which of the following should the nurse anticipate administering? A. Diphtheria, tetanus, and acellular pertussis (DTAP) vaccine B. Single injection of tetanus immune globulin (TIG) mixed with pediatric tetanus booster (DT) C. Tetanus, diphtheria, and acellular pertussis (Tdap) vaccine D. Adult tetanus booster (Td)

Correct Answer: C. Administer IV fluid replacement ** The greatest risk to this child is an injury from hypovolemic shock; therefore, the first action the nurse should take after ensuring the child has a patent airway is to administer IV fluid replacement therapy. Incorrect Answers: A. The nurse should administer IV morphine to reduce and control the child's pain and level of anxiety; however, there is another action the nurse should take first. B. The nurse should administer topical antimicrobials to the burn wounds to reduce the child's risk of infection; however, there is another action the nurse should take first. D. The nurse should administer tetanus prophylaxis to reduce the child's risk of tetanus infection; however, there is another action the nurse should take first.

A nurse in the emergency department is admitting a child who has full-thickness burns over 45% of his body. Which of the following actions should the nurse take first? A. Administer IV morphine B. Administer topical antimicrobials C. Administer IV fluid replacement D. Administer tetanus prophylaxis

Correct Answer: D. Bruises at various stages of healing ** The nurse should recognize that bruises at various stages of healing are a manifestation of physical abuse. Incorrect Answers: A. Depriving a child of medical and dental care is a manifestation of physical neglect. B. Malnutrition is a manifestation of physical neglect. C. Frequent urinary tract infections are a manifestation of sexual abuse.

A nurse in the emergency department is assessing a preschooler for indications of child maltreatment. The nurse should identify that which of the following findings is a manifestation of physical abuse? A. Multiple dental caries B. Malnutrition C. Frequent urinary tract infections D. Bruises at various stages of healing

Correct Answer: C. Vomiting ** The nurse should identify that vomiting, especially when unrelated to feedings, is a manifestation of digoxin toxicity. The nurse should report this finding to the provider immediately. Incorrect Answers: A. Irritability is not a manifestation of digoxin toxicity. B. Diaphoresis is not a manifestation of digoxin toxicity. D. Bradycardia, not tachycardia, is a manifestation of digoxin toxicity.

A nurse in the emergency department is assessing an infant who recently started taking digoxin to treat a supraventricular arrhythmia. Which of the following findings should the nurse identify as an indication of digoxin toxicity? A. Irritability B. Diaphoresis C. Vomiting D. Tachycardia Answer

Correct Answer: C. "Injury by a corrosive liquid is more extensive than by a corrosive solid." ** The coating action of liquids permits larger areas of contact with tissues and results in more extensive injury. Incorrect Answers: A. The absence of oral or pharyngeal burns does not eliminate the possibility of esophageal burns. The existence and extent of burns depend on the substance and the length of time it has been in contact with tissues. A burn may be present in the esophagus but not in the mouth. B. Neutralization can result in heat injury to tissues due to an exothermic reaction. This might cause both chemical and thermal burns of tissues. D. Activated charcoal is not administered to an adolescent who has ingested a corrosive substance because it can infiltrate any tissue that is burned.

A nurse in the emergency department is caring for a 12-year-old child who has ingested bleach. Which of the following statements by the nurse indicates an understanding of this ingestion? A. "The absence of oral burns excludes the possibility of esophageal burns." B. "Treatment focuses on neutralization of the chemical." C. "Injury by a corrosive liquid is more extensive than by a corrosive solid." D. "Immediate administration of activated charcoal is warranted."

Correct Answer: B. Check the child's respiratory status ** The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. This child's lips are edematous and inflamed, and he is drooling. These findings indicate that the child might have swelling of the oral cavity and pharynx, which can result in a compromised airway. Incorrect Answers: A. The nurse should remove the child's contaminated clothing to prevent further exposure to the substance; however, a different action is thepriority. C. The nurse may administer an antidote if available for the substance ingested; however, a different action is the priority. D. The nurse should establish IV access because shock is a complication of some poisons; however, a different action is the priority.

A nurse in the emergency department is caring for a 2-year-old child who was found by his parents crying and holding a container of toilet bowl cleaner. The child's lips are edematous and inflamed, and he is drooling. Which of the following is the priority action by the nurse? A. Remove the child's contaminated clothing B. Check the child's respiratory status C. Administer an antidote to the child D. Establish IV access for the child

Correct Answer: D. Acetylcysteine ** The nurse should expect to administer acetylcysteine to the child because it is an antidote to acetaminophen. Incorrect Answers: A. The nurse should expect to administer naloxone if the child is experiencing respiratory depression resulting from an opioid; however, naloxone is not indicated as a treatment for an overdose of acetaminophen. B. The nurse should expect to administer diphenhydramine if the child is experiencing an allergic reaction to a medication; however, diphenhydramine is not indicated as a treatment for an overdose of acetaminophen. C. The nurse should expect to administer glucagon if the child is experiencing hypoglycemia; however, glucagon is not indicated as a treatment for an overdose of acetaminophen.

A nurse in the emergency department is caring for a child who accidentally ingested an overdose of acetaminophen. Which of the following medications should the nurse expect to administer? A, Naloxone B. Diphenhydramine c. Glucagon D. Acetylcysteine

Correct Answer: D. Report the suspected abuse to local authorities ** The nurse should initiate the process of removing the child from the abusive environment by following the facility's protocol for reporting the situation to child protective services or local law enforcement. Incorrect Answers: A. The nurse should avoid the use of the term "abuse" and should ask the child to describe what happened without making an accusation or placing blame on an individual. B. A risk manager evaluates situations that could create liability for the facility. In this situation, the child is not at risk from the facility or staff. C. The nurse should interview the child privately to provide a safe environment in which the child feels able to talk about what happened.

A nurse in the emergency department is caring for a child who has bruises that support a suspicion of child abuse. Which of the following actions should the nurse take? A. Ask the child if his parents are responsible for the abuse B. Notify the facility's risk manager C. Interview the child with his parents present D. Report the suspected abuse to local authorities

Correct Answer: B. 12 months old ** The nurse should know that this infant must be less than 18 months old because her anterior fontanel is still open. The infant is approximately 12 months old due to the presence of 6 teeth. Her skills-sitting unsupported (8 months), drinking well from a cup (9 months), stranger anxiety (8 months), and ability to say 2 words (12 months)-should also help the nurse estimate the infant's age as 12 months. Incorrect Answers: A. At 6 months, an infant would not have 6 teeth or demonstrate these skills. C. The infant must be younger than 18 months old since her anterior fontanel is still open. In addition, an infant of this age should have 12 teeth. D. At 24 months, an infant should have all of her primary teeth and be able to speak in 2-word phrases.

A nurse in the emergency department is caring for an unaccompanied infant following a motor-vehicle crash. During the assessment, the nurse notes that the infant's anterior fontanel is almost closed. She has 6 teeth, is able to sit unsupported, and can drink from a cup. The child cries whenever anyone new to her enters the room, says a few words, and is asking for "mama" and "dada." The nurse should make which of the following age assessments for this child? A. 6 months old B. 12 months old C. 18 months old D. 24 months old

Correct Answer: C. An infant with a WBC count of 24,000/mm3 ** The nurse should apply the safety and risk-reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. This WBC count is high and indicates infection and possibly sepsis, which poses the greatest The provider must initiate blood, urine, and spinal fluid cultures and begin antimicrobial therapy. Incorrect Answers: A. A slightly elevated specific gravity can indicate dehydration; however, it is not a reliable measure in children. While this child requires evaluation for influenza manifestations, another client's immediate needs are the priority. B. Although this toddler's BUN is slightly elevated, the creatinine is within the expected reference range. These findings indicate dehydration, which is expected with influenza manifestations. While the toddler requires evaluation, another client's immediate needs are the priority. D. This finding indicates pregnancy. This client does require care and counseling; however, another client's immediate needs are the priority.

A nurse in the emergency department is reviewing laboratory results for several children who have manifestations of influenza. Which of the following children should the nurse report to the provider immediately? A. A school-age child with a urine specific gravity of 1.035 B. A toddler with a BUN of 25 mg/dL and a creatinine of 0.5 mg/dL C. An infant with a WBC count of 24,000/mm3 D. An adolescent with a positive beta human chorionic gonadotropin test

Correct Answer: C. Put a "no abdominal palpation" sign over the child's bed. ** The nurse should place a sign over the child's bed stating "no abdominal palpation" because palpation is not necessary to confirm diagnosis and could prompt metastasis. Incorrect Answers: A. Contact precautions are indicated for children who are suspected to have illnesses transmitted by client contact or contact with items in the client's environment. B. Radiology and chemotherapy are begun immediately following surgery. D. A spinal tap is a diagnostic test that provides samples of spinal fluid to confirm infection or abnormal cells.

A nurse is admitting a child who has Wilms' tumor. Which of the following actions should the nurse take? A, Initiate contact precautions for the child. B. Explain to the child's parents that chemotherapy will start 3 months after surgery. C. Put a "no abdominal palpation" sign over the child's bed. D. Prepare the child for a spinal tap.

Correct Answer: D. Suction equipment ** When using the airway, breathing, and circulation (ABC) approach to client care, the nurse should determine that the priority item to have in the child's room is suction equipment. If the child experiences a tonic-clonic seizure, the child is at risk for aspiration and airway occlusion due to secretions, food, or fluids. The nurse should have suction equipment available to maintain a patent airway for effective respiration, administration of oxygen, and use of a bag valve mask if needed. Incorrect Answers: A. The nurse should have a pulse oximeter available in the child's room because the child is at risk for hypoxia from a tonic-clonic seizure; however, another item is the priority for the nurse to have in the child's room. B. The nurse should have oxygen therapy equipment available in the child's room because the child is at risk for hypoxia from a tonic-clonic seizure; however, another item is the priority for the nurse to have in the child's room. C. The nurse should have a bag valve mask available in the child's room because the child might need rescue breaths following a tonic-clonic seizure; however, another item is the priority for the nurse to have in the child's room,

A nurse is admitting a child who has a history of tonic-clonic seizures. Which of the following items is the priority to have in the child's room? A. Pulse oximeter B. Oxygen therapy C. Bag valve mask D. Suction equipment

Correct Answer: A. Attach a latex allergy alert identification band ** Myelomeningocele, a serious complication of spina bifida, is a neural tube defect in which the spinal cord and meninges are in a cerebrospinal fluid-filled sac at birth. Clients who have neural tube defects are at risk of latex allergy; therefore, the nurse should avoid the use of common medical products containing latex such as latex gloves for this client. Incorrect Answers: B. UTI is a common complication of myelomeningocele. However, neither myelomeningocele nor UTI requires contact precautions. C. UTI is a common complication of myelomeningocele. Straining urine is essential for urolithiasis (urinary calculi) or stones in the urinary system, not for myelomeningocele or UTI. D. Women should take folic acid during pregnancy to reduce the risk of neural tube defects such as myelomeningocele.

A nurse is admitting a child who has a urinary tract infection (UTI) and a history of myelomeningocele. After completing the admission history, which of the following actions should the nurse plan to take? A. Attach a latex allergy alert identification band B. Initiate contact precautions C. Post signs in the client's bathroom to strain the client's urine D. Administer folic acid with meals

Correct Answer: B. RBCS 2.5 million/ul ** An RBC count of 2.5 million/ul is below the expected reference range. A child who has acute lymphocytic leukemia has a low RBC count. Incorrect Answers: A. A platelet count of 500,000 mm^3 is above the expected reference range. A child who has acute lymphocytic leukemia has a low platelet count. C. A WBC count of 4,000/mm^3 is below the expected reference range. A child who has acute lymphocytic leukemia has a very high WBC count. D. An Hct level of 60% is above the expected reference range. A child who has acute lymphocytic leukemia has a low Hct level.

A nurse is admitting a child who has acute lymphocytic leukemia. Which of the following laboratory values should the nurse expect? A. Platelets 500,000 mm^3 B. RBCS 2.5 million/ul c. WBCS 4,000/mm^3 D. Hct 60%

Correct Answer: C. A blue coloring of the sclera ** This discoloration is associated with osteogenesis imperfecta, a genetic disorder that results in bone fragility. The nurse should notify the provider of this finding. Incorrect Answers: A. This discoloration is known as a nevus simplex, or stork bite. It typically blanches with pressure and becomes more prominent with crying. This finding does not require notification of the provider. B. This discoloration is known as a Mongolian spot. It is typically observed in infants who have increased skin pigmentation (e.g., those of African, Asian, or Hispanic descent) and does not require notification of the provider. D. This discoloration is known as erythema toxicum, or newborn rash. It is a benign, transient finding and does not require notification of the provider.

A nurse is assessing a 1-week-old infant at a well-child visit. The nurse should notify the provider about which of the following assessment findings? A. A flat, dark pink area between the eyes that blanches B. An area of deep blue pigmentation over the buttocks C. A blue coloring of the sclera D. A patchy, red rash with raised centers

Correct Answer: D. The infant needs assistance to sit up ** An infant is expected to have the ability to sit up unsupported around 8 months of age. Therefore, the nurse should report this finding to the provider. Incorrect Answers: A. Although infants develop at different rates, the infant may not begin walking independently until 13 months of age. Therefore, the nurse should identify this as an expected finding for a 10-month-old infant. B. The infant's Moro reflex is expected to disappear around 4 months of age. Therefore, the nurse should identify this as an expected finding for a 10-month-old infant. C. The infant's anterior fontanel is expected to close around 12 months of age. Therefore, the nurse should identify this as an expected finding for a 10-month-old infant.

A nurse is assessing a 10-month-old infant at a well-infant checkup. Which of the following assessment findings should the nurse report to the provider? A. The infant is unable to walk independently B. The infant's Moro reflex is absent C. The infant's anterior fontanel is open D. The infant needs assistance to sit

Correct Answer: A. Heart rate 175/min ** A heart rate of 175/min is above the expected reference range for a 12-month-old infant; therefore, the nurse should report this finding to the provider. Incorrect Answers: B. A respiratory rate of 26/min is within the expected reference range for a 12-month-old infant. C.A blood pressure of 88/40 mmHg is within the expected reference range for a 12-month-old infant. D. A temperature of 37.6°C (99.7°F) is within the expected reference range for a 12-month-old infant.

A nurse is assessing a 12-month-old male infant's vital signs during a well-child visit. The infant is in the 90th percentile for height. Which of the following findings should the nurse report to the provider? A. Heart rate 175/min B. Respiratory rate 26/min C. Blood pressure 88/40 mmHg D. Temperature 37.6°C (99.7°F)

Correct Answer: B. Hyperopia ** The nurse should report hyperopia in a 12-year-old child to the provider. Hyperopia, or farsightedness, is an unexpected finding after the age of 7. Incorrect Answers: A. Five centimeters of growth per year is an expected finding for school-age children. C. The development of secondary sex characteristics, including the presence of pubic hair, can be an expected finding for a 12-year-old child. D. A weight gain of 2 to 3 kg (4.4 to 6.6 lb) per year is an expected finding for school-age children.

A nurse is assessing a 12-year-old child during a well-child checkup. Which of the following physical findings should the nurse report to the provider? A. 5 cm (2 in) of growth in the past year B. Hyperopia C. Presence of pubic hair D. Weight gain of 3 kg (6.6 lb) in the last year

Correct Answer: A. Weight gain of 1.8 kg (4 lb) A 4 lb weight gain indicates increased fluid and worsening of the child's heart failure; therefore, the nurse should report this finding to the provider. Incorrect Answers: B. A heart rate of 125/min is an expected finding in a 2-month-old infant. C. A soft, flat fontanel is an expected finding in a 2-month-old infant. D. A systemic murmur is an expected finding in an infant who has a ventricular septal defect.

A nurse is assessing a 2-month-old infant who has a ventricular septal defect. Which of the following findings should the nurse report to the provider? A. Weight gain of 1.8 kg (4 lb) B. Heart rate of 125/min C. Soft, flat fontanel D. Systemic murmur

Correct Answer: C. Impaired language skills ** The nurse should expect a 24-month-old toddler who has ASD to exhibit impaired language skills (e.g. failing to respond to his or her name, pointing to objects instead of speaking). Incorrect Answers: A. Physical contact and being held will often upset children who have ASD. The nurse should expect a toddler who has ASD to avoid physical touch. B. The nurse should identify that building a tower of 10 cubes is an expected finding for a 3-year-old preschooler. D. The nurse should identify that standing on 1 foot for a few seconds is an expected gross motor skill for a 3-year-old preschooler.

A nurse is assessing a 24-month-old toddler who has a new diagnosis of autism spectrum disorder (ASD). Which of the following findings should the nurse еxpect? A. Wanting to be held frequently B. Ability to build a tower of 10 cubes C. Impaired language skills D. Ability to stand on 1 foot

Correct Answer: C. The child cannot walk on tiptoe ** The nurse should identify that a child should be able to take a few steps on tiptoe by 30 months of age. Therefore, the nurse should report this finding to the provider. Incorrect Answers: A. The nurse should identify that bedwetting during sleep is an expected finding for a 3-year-old child. Nighttime bladder control can take months to a few years to achieve following daytime bladder control. B. The nurse should identify that the ability to catch a ball occurs when a child is 4 to 5 years old. A 3-year-old child does not have the gross motor skills necessary to perform this skill. D. The nurse should identify that building a tower of 10 cubes is an expected finding for a 3-year-old child. The child should also have the fine motor skills to copy a circle when drawing and place beads into a small bottle.

A nurse is assessing a 3-year-old child during a well-child examination. Which of the following findings should the nurse report to the provider? A. The child wets the bed when sleeping B. The child cannot catch a ball C. The child cannot walk on tiptoe D. The child builds a tower of 10 cubes

Correct Answer: B. Use the FACES scale ** Pain is a subjective experience, even for a 3-year-old child. The FACES scale can be used to determine the presence of pain in children as young as 3 years of age. Incorrect Answers: A. Asking the parents is not appropriate, as pain is considered a personal experience. C. The numeric rating scale is appropriate for children who are 5 years of age or older. D. The child's temperature is not an indicator of pain. While changes in heart rate, BP, and respiratory rate can be indicators of pain, they not reliable because pain is a subjective manifestation.

A nurse is assessing a 3-year-old child who is 1 day postoperative following a tonsillectomy. Which of the following methods should the nurse use to determine if the child is experiencing pain? A. Ask the parents B. Use the FACES scale C. Use the numeric rating scale D. Check the child's temperature

Correct Answer: A. Stacking 10 blocks ** The nurse should expect a 3-year-old preschooler to have the fine motor ability to stack 10 blocks. Incorrect Answers: B. The nurse should expect a 3-year-old preschooler to have the ability to draw a circle but not print letters until age 5. C. The nurse should expect a 3-year-old preschooler to have the fine motor ability to put on shoes but not tie shoelaces until age 5. D. The nurse should expect a 3-year-old preschooler to have the language ability to use 3- to 4-word sentences. Seven-word sentences are not expected until age 5.

A nurse is assessing a 3-year-old preschooler. Which of the following developmental milestones should the nurse expect the preschooler to demonstrate? A. Stacking 10 blocks B. Printing 1 letter C. Tying shoelaces D. Using 7-word sentences

Correct Answer: C. The toddler's birth weight is tripled. The toddler's birth weight should triple by 12 months of age. By 30 months of age, the toddler's birth weight should be quadrupled. Incorrect Answers: A. This is an expected finding in a 30-month-old toddler. At this age, the toddler should have all 20 deciduous teeth. B. The skill of hopping on 1 foot is not developed until around the age of 4 years. D. This is expected finding in a toddler at the age of 30 months. At this age, the toddler should be able to state her first and last name.

A nurse is assessing a 30-month-old toddler during a well-child visit. Which of the following findings requires further assessment by the nurse? A. Primary dentition is complete. B. The toddler is unable to hop on 1 foot. C. The toddler's birth weight is tripled. D. The toddler is able to state her first and last name.

Correct Answer: C. Speaking using 2- or 3-word sentences ** A 4-year-old child should be speaking in 4- to 5-word sentences. Speaking in 2- to 3-word sentences is typical of a 2-year-old child. Incorrect Answers: A. Tying shoelaces is a skill expected of a 5-year-old child. B. This is an expected finding in a 4-year-old child. D. Walking backward is a skill expected of a 5-year-old child.

A nurse is assessing a 4-year-old child for growth and developmental milestones during a well-child visit. Which of the following findings suggests a possible delay in development? A. Inability to tie shoes B. Adding 3 parts to a stick figure C. Speaking using 2- or 3-word sentences D. Inability to walk backward

Correct Answer: B. Development of the superego ** This is the development of a conscience. Preschoolers begin to develop an understanding of right from wrong. While they might be unable to understand the "why" of acceptable vs unacceptable behaviors, they learn the concept through punishment and reward and the principles to which their parents adhere. Incorrect Answers: A. Conservation is the ability to understand that quantity does not change if shape changes. The ability to understand conservation typically develops in a school-age child. C. This is the ability to use previous experiences to solve current problems, which typically develops in the school-aged child. D. Preschoolers are typically able to tolerate brief periods of separation from their parents and interact with unfamiliar persons. Separation anxiety typically develops in infants around 10 months of age.

A nurse is assessing a 4-year-old child's cognitive development during a well-child visit. Which of the following should the nurse expect the child to display? A. Conservation B. Development of the superego C. Concrete operational thought D. Separation anxiety

Correct Answer: A. Fastening buttons on a shirt The nurse should expect a 4-year-old child to have the fine motor ability to fasten buttons on a shirt; however, the child may have difficulty if the buttons are small. Incorrect Answers: B. The nurse should expect a 4-year-old child to have the fine motor ability to lace shoes; however, tying shoelaces is a fine motor skill expected of a 5-year-old child. C. The nurse should expect a 7-year-old child to have the fine motor ability to part and comb his/her hair without the need of assistance. D. The nurse should expect a 7-year-old child to have the fine motor ability to cut tender pieces of meat with a table knife.

A nurse is assessing a 4-year-old child. The nurse should expect the child to be able to perform which of the following activities? A. Fastening buttons on a shirt B. Tying shoelaces C. Parting and combing hair D. Cutting the meat at dinner

Correct Answer: C. The infant's legs remain crossed and extended when supine. ** Legs that are crossed and extended when supine is an unexpected finding and requires further assessment. At 6 months of age, the infant's legs flex at the knees when the infant is supine. Crossed and extended legs when supine is associated with cerebral palsy. Incorrect Answers: A. Infants are able to grab the feet and pull them to their mouth at 6 months of age. At this age, the infant should also be able to pick up a dropped object and hold a bottle. B. This is an expected finding in a 6-month-old infant. The posterior fontanel closes at approximately 2 months of age. The anterior fontanel is closed by 18 months of age. D. Infants should double their birth weight by 6 months and triple their birth weight by 12 months.

A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings indicates the need for further assessment? A. The infant is grabbing the feet and pulling them to the mouth. B. The infant has a closed posterior fontanel. C. The infant's legs remain crossed and extended when supine. D. The infant's birth weight has doubled.

Correct Answer: D. Turning from back to stomach ** A 6-month-old infant should be able to turn over completely, sit momentarily without support, and reach to be picked up Incorrect Answers: A. A 6-month-old infant is not able to sit alone. Infants usually achieve this motor activity around 9 months of age. B. A 6-month-old infant cannot stack objects. A 12-month-old infant might attempt to build a 2-block tower but usually fails. C. A 6-month-old infant cannot pick up objects with a crude pincer grasp. Infants usually achieve this motor activity around 9 months of age.

A nurse is assessing a 6-month-old infant during a well-child visit. Which of the following motor activities should the nurse expect the infant to have achieved? A. Sitting alone B. Attempting to stack objects C. Picking up small objects with a crude pincer grasp D. Turning from back to stomach

Correct Answer: C. BP 86/40 mmHg ** A BP of 86/40 mmHg is indicative of hypotension and bleeding in a 6-month-old infant and should be immediately reported to the provider. Incorrect Answers: A. This temperature is within the expected reference range for a 6-month-old infant. B. This apical pulse level is within the expected reference range for a 6-month-old infant. D. This respiratory rate is within the expected reference range for a 6-month-old infant.

A nurse is assessing a 6-month-old infant following a cardiac catheterization. Which of the following findings should the nurse report to the provider? A. Temperature 37.5°C (99.5°F) B. Apical pulse rate 140/min C. BP 86/40 mmHg D. Respiratory rate 32/min

Correct Answer: A. Cool toes on the right foot ** The nurse should monitor the temperature of the infant's right extremity and should report any indication of coolness distal to the entry site to the provider because this can indicate an obstruction of an artery. Incorrect Answers: B. The nurse should monitor the infant's pedal pulses for bilateral symmetry and equal strength. The nurse should expect the pedal pulse distal to the entry site to be weak after the procedure; however, it should gradually increase in strength. C. The nurse should expect infants to have a positive Babinski reflex until about 12 months of age. D. The nurse should monitor the color of the infant's right extremity and should report any indication of pallor or blanching to the provider because this can indicate an obstruction of an artery.

A nurse is assessing a 6-month-old infant who hada cardiac catheterization with right femoral entry to diagnose a possible congenital heart defect. Which of the following findings should the nurse report to the provider? A. Cool toes on the right foot B. Weak pedal pulses on both feet C. Positive Babinski reflex on both feet D. Erythema on the right foot

Correct Answer: C. Tachypnea ** An infant who has moderate dehydration will have slight tachypnea. Incorrect Answers: A. An infant who has moderate dehydration will have a flat or sunken fontanel. B. An infant who has moderate dehydration will have a slightly increased heart rate. D. An infant who has moderate dehydration will have decreased urinary output.

A nurse is assessing a 6-month-old infant who was recently admitted with acute vomiting and diarrhea. Which of the following findings indicates the infant has moderate dehydration? A. Bulging anterior fontanel B. Bradycardia C. Tachypnea D. Polyuria

Correct Answer: B. Move a brightly colored toy from side to side in front of the infant's face ** The nurse should check the infant's ability to see by positioning the infant upright and holding a brightly colored toy or object in front of the infant's face and moving it from side to side. The nurse should observe the infant's ability to fixate on the toy and track its movement. The nurse can also perform this assessment using the human face as a visual target. Incorrect Answers: A. The nurse should use this technique to check light perception and pupillary constriction; however, this assessment does not check the infant's ability to see. C. The nurse can use the human face to check the infant's vision; however, up and down movement will not provide adequate data about the infant's ability to track movement. D. The nurse should observe the infant's ability to grasp the feet and pull them to the mouth as part of a developmental assessment; however, the nurse should use a different technique to check the infant's visual acuity.

A nurse is assessing a 6-month-old infant. The guardian reports that the infant does not appear interested in the brightly colored mobile hanging above the crib at home. Which of the following techniques should the nurse use to check the infant's visual acuity? A. Shine a penlight briefly into the left eye and then the right eye B. Move a brightly colored toy from side to side in front of the infant's face C. Ask the guardian to sit in front of the infant and nod his head up and down D. Observe the infant's ability to grasp the feet and pull them to the mouth

Correct Answer: B. Heart rate 118/min ** The nurse should identify that a heart rate of 118/min is within the expected reference range for a 6-year-old child. A child who has an acute pneumococcal pneumonia infection will exhibit tachycardia. Incorrect Answers: A. The nurse should identify that dullness with chest percussion is an indication of consolidation of infection. Therefore, this finding does not indicate that treatment has been effective. C. The nurse should identify that conjunctival discharge is a manifestation of allergic rhinitis or conjunctivitis. This finding does not indicate effective treatment of pneumococcal pneumonia. D. The nurse should identify that a respiratory rate of 28/min is above the expected reference range for a 6-year-old child. A child who has pneumococcal pneumonia will exhibit tachypnea and shallow respirations.

A nurse is assessing a 6-year-old child who began treatment for pneumococcal pneumonia 4 days ago. Which of the following findings should the nurse identify as an indication the treatment is effective? A. Dullness with chest percussion B. Heart rate 118/min c. Conjunctival discharge D. Respiratory rate 28/min

Correct Answer: B. The child is swallowing frequently ** The nurse should identify that frequent swallowing is a manifestation of hemorrhage. Therefore, the nurse should immediately notify the provider of this finding. Incorrect Answers: A. The nurse should identify that a small amount of dark brown blood between the teeth is an expected finding following a tonsillectomy. The child might also have dark brown blood in the nares. C. The nurse should identify that a heart rate of 118/min is within the expected reference range for a 6-year-old child. D. The nurse should identify that refusing an ice collar is an expected response from a child who is postoperative following a tonsillectomy.

A nurse is assessing a 6-year-old child who is immediately postoperative following a tonsillectomy. Which of the following findings should the nurse report the provider? A, The child has a small amount of dark brown blood between the teeth B. The child is swallowing frequently C. The child has a heart rate of 118/min D. The child refuses the application of an ice collar

Correct Answer: A. Presence of sparse, fine pubic hair ** The development of sexual characteristics prior to the age of 9 years in boys and 8 years in girls is an indication of precocious puberty and requires further evaluation. Incorrect Answers: B. The head circumference of a school-age child decreases when compared to full height due to skeletal lengthening. C. Body proportion varies with a slimmer appearance and longer legs in a school-age child. Leg length increases and waist circumference decreases related to height in this age group. D. The deciduous teeth start shedding at this age, beginning with the lower central incisors.

A nurse is assessing a 6-year-old client at a well-child visit. Which of the following findings requires further assessment by the nurse? A. Presence of sparse, fine pubic hair B. Decreased head circumference compared to full height C. Increased leg length in relation to height D. Presence of a loose central incisor

Correct Answer: C. The child complains daily about going to school. ** Complaining every day about going to school is an unexpected finding for a 7-year-old child. The child is in Erikson's psychosocial development stage of industry vs. inferiority. Children at this stage want to learn and master new concepts. If the child complains daily about going to school, further evaluation is warranted. Incorrect Answers: A. Male and female children who are 7 years old prefer to play with peers who are the same gender. B. School-age children enjoy engaging in various types of competitive games and are learning about the concept of winning. D. A 7-year-old child does not require the same level of companionship as older school-age children; therefore, the fact that this child spending time alone is an expected finding.

A nurse is assessing a 7-year-old child's psychosocial development. Which of the following findings should the nurse recognize as an indicator for further evaluation? A. The child prefers playmates of the same sex. B. The child is competitive when playing board games. C. The child complains daily about going to school. D. The child enjoys spending time alone.

Correct Answer: B. Inability to vocalize vowel sounds ** The infant should begin vocalizing vowel sounds at the age of 7 months. By the age of 10 months, the infant should be able to say at least 1 word. Incorrect Answers: A. The infant should creep on hands and knees at the age of 9 months and begin to stand while holding onto furniture at the age of 10 months, C. Most infants demonstrate a crude pincer grasp at 9 months of age; the use of a dominant hand is also evident. D. The ability to stand while holding onto a support is typically present at 10 months of age.

A nurse is assessing a 9-month-old infant during a well-child visit. Which of the following findings indicates that the infant has a developmental delay? O A. Creeping on hands and knees B. Inability to vocalize vowel sounds c. Using a crude pincer grasp D. Standing by holding onto a support

Correct Answer: B. Requiring support to sit for prolonged periods ** An infant should be able to sit unsupported by the age of 8 months. The nurse should report this finding to the provider because it is an indication of a delay in gross motor development. Incorrect Answers: A. The use of a pincer grasp usually begins to appear at the age of 8 months and becomes more refined by the age of 9 months. This is an indication that the infant's fine motor skills are on track with expected findings. C. An infant begins to localize sounds by the age of 3 months. By 9 months of age, the infant should be able to turn the head toward the location of the sound. This is an indication that the infant's sensory skills are on track with expected findings. D. An infant begins to vocalize chained syllables such as "dada" by the age of 7 months of age. By 10 months of age, the infant associates meaning with words such as "mama." This is an indication that the infant's vocalization skills are ahead of expected findings.

A nurse is assessing a 9-month-old infant. Which of the following findings should the nurse report to the provider as a delay in development? A. Using a pincer grasp to pick up blocks B. Requiring support to sit for prolonged periods C. Turning the head toward the parent's voice D. Reaching for the mother and saying "mama"

Correct Answer: B. Dropping a cube when passing from 1 hand to the other ** The ability to pass a cube from a hand to the other is a fine motor skill expected of a 7-month-old infant. Therefore, the nurse should identify the 9-month-old infant's inability to perform this task as a possible developmental delay and should report this finding to the provider. Incorrect Answers: A. The pincer grasp is an expected fine motor skill for a 9-month-old infant. C. Falling down to a sitting position from a standing position is an expected gross motor skill for a 9-month-old infant. D. A 9-month-old infant should have the gross motor ability to maintain balance while leaning forward in a sitting position; however, the infant does not yet have the ability to maintain balance while leaning sideways.

A nurse is assessing a 9-month-old infant. Which of the following findings should the nurse report to the provider as a possible developmental delay? A. Grasping a small object with just the thumb and index finger B. Dropping a cube when passing from 1 hand to the other C. Falling from a standing position to sitting D. Losing balance when leaning sideways while sitting

Correct Answer: B. Murmur at the left sternal border ** A ventricular septal defect (a hole in the septal wall between the ventricles) is an acyanotic heart defect. A systolic murmur can be heard at the lower left sternal border, The sound is transmitted in the direction of blood flow, so any backflow of blood from the left to the right ventricle through the septal defect is best heard in this area. Incorrect Answers: A. A diastolic murmur is an expected finding in a child who has an atrial septal defect. C. Cyanosis that increases with crying is an expected finding in a child who has an atrioventricular canal defect. D. Widened pulse pressure is an expected finding in a child who has patent ductus arteriosus.

A nurse is assessing a child who has a ventricular septal defect. Which of the following findings should the nurse expect? A. Diastolic murmur B. Murmur at the left sternal border C. Cyanosis that increases with crying D. Widened pulse pressure Answer

Correct Answer: A. Hypertension **The nurse should expect a child who has pheochromocytoma to exhibit hypertension due to the increased production of catecholamines. Other manifestations include sweating, weight loss, and polyuria. Incorrect Answers: B. The nurse should expect a child who has pheochromocytoma to exhibit anorexia and weight loss. C. The nurse should expect a child who has pheochromocytoma to exhibit tachycardia. D. The nurse should expect a child who has pheochromocytoma to exhibit constipation.

A nurse is assessing a child who has bilateral pheochromocytoma. Which of the following findings should the nurse expect? A. Hypertension B. Abdominal obesity C. Bradycardia D. Loose stools

Correct Answer: A. Chills and flank pain ** Chills and flank pain indicate an incompatibility of the transfused blood product with the client's blood. The nurse should identify that the child is having a hemolytic reaction. Incorrect Answers: B. Pruritus and flushing indicate a response to allergens present in the transfused blood product. The nurse should identify that the child is having an allergic reaction. C. Rales and cyanosis indicate the blood product might have been administered too quickly. The nurse should identify these findings as an indication the child is experiencing fluid overload. D. Bradycardia and diarrhea indicate a complication due to the transfusion of large amounts of blood or a problem with the kidneys. The nurse should identify these findings as an indication the child is experiencing an electrolyte imbalance.

A nurse is assessing a child who is postoperative and received a unit of packed RBCS during a surgical procedure. Which of the following findings indicates the child is experiencing a hemolytic transfusion reaction? A. Chills and flank pain B. Pruritus and flushing C. Rales and cyanosis D. Bradycardia and diarrhea

Correct Answer: B. Respiratory depression ** The nurse should monitor the child's respiratory status postoperatively and plan to administer naloxone if respiratory depression is present. Naloxone is an opioid antagonist used to reverse the effects of opioids administered perioperatively. Incorrect Answers: A. The nurse should monitor the child's lung sounds postoperatively. Crackles in the lung bases can indicate atelectasis, which indicates the need to promote lung expansion. However, this is not an indication for the administration of naloxone. C. The nurse should monitor the child for nausea and vomiting postoperatively. This postoperative complication can occur as a result of abdominal distention or pain and as an adverse effect of medications. However, this is not an indication for the administration of naloxone. D. The nurse should monitor the child's heart rate and vital signs postoperatively. Tachycardia can be an indicator of pain, hemorrhage, or hypoxemia indicating the need for further assessment. However, tachycardia is not an indication for the administration of naloxone.

A nurse is assessing a child who is postoperative. Which of the following findings should the nurse identify as an indication that naloxone should be administered? A. Crackles in the lung bases B. Respiratory depression C. Nausea and vomiting D. Tachycardia

Stop the infusion Elevate the extremity Notify the provider Remove the IV line

A nurse is assessing a child who is receiving IV chemotherapy. Assessment findings include extravasation of the tissues surrounding the IV insertion site. In which order should the nurse take the following actions? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) Stop the infusion Notify the provider Remove the IV line Elevate the extremity

Correct Answer: B. Test the nasal secretions for glucose ** The nurse should test the nasal secretions for glucose with a reagent strip to determine if the secretions are a leakage of cerebrospinal fluid (CSF). The leakage of CSF is positive for glucose and occurs if the child has a skull fracture. Incorrect Answers: A. The nurse should avoid performing nasotracheal suctioning. This procedure is contraindicated due to the risk of injury to the child's brain if a skull fracture is present. C. The nurse should avoid bright lights due the child's risk of increased intracranial pressure. The nurse should provide an environment with decreased stimulation. D. The nurse should position the child with the head of the bed elevated and the child's head in a midline position to assist with preventing increased intracranial pressure.

A nurse is assessing a child who sustained a head injury. During the assessment, the nurse observes clear drainage leaking from the child's nose. Which of the following actions should the nurse take? A. Perform nasotracheal suctioning B. Test the nasal secretions for glucose C. Maintain direct lighting on the child D. Lower the head of the bed

Correct Answer: C. 9 ** Apgar scoring is an evaluation of a newborn's heart rate, respiratory effort, muscle tone, reflexes, and color. A maximum score of 2 is assigned for each parameter. This infant lost 1 point for the presence of acrocyanosis. Incorrect Answers: A. A newborn who has a score of 7 would have at least 3 areas lacking in peak response or1-2 areas of additional deficiency. The only deficiency this infant has is cyanosis of the hands and feet, which results in a loss of 1 point. B. A newborn who has a score of 8 would have at least 2 areas lacking in peak response or 1 area of additional deficiency. The only deficiency this infant has is cyanosis of the hands and feet, which results in a loss of 1 point. D. An infant who has an Apgar score of 10 would have earned the maximum for each parameter, but this infant has a deficiency in circulation indicated by acrocyanosis.

A nurse is assessing a newborn at birth to assign Apgar scores. At 1 min of age, the newborn is crying vigorously with limbs flexed and has a heart rate of 120/min. The newborn's trunk is pink, but his hands and feet are cyanotic, and he cries when the soles of his feet are stimulated. Which of the following Apgar scores should the nurse assign this infant? A.7 B. 8 c.9 D. 10

Correct Answer: C. The child is drooling ** When using the urgent versus nonurgent approach to client care, the nurse should determine that the presence of drooling is the priority finding because it can indicate the child might have developed epiglottitis, a medical emergency. Left untreated, the child can develop a complete respiratory obstruction. Incorrect Answers: A. A finding of sallow skin is an expected finding for a child who is ill. Therefore, there is another finding that is the nurse's priority. B. An elevated temperature is an expected finding for a child who has influenza. Therefore, there is another finding that is the nurse's priority. D. A report of a hoarse voice is an expected finding for a child who has a sore throat. Therefore, there is another finding that is the nurse's priority.

A nurse is assessing a preschooler who has influenza and reports the new onset of a sore throat and difficulty swallowing. Which of the following findings is the priority for the nurse to report to the provider? A. The child's temperature is 39°C (102°F) B. The child's skin is sallow C. The child is drooling D. The child's voice is hoarse

Correct Answer: B. "Does anyone smoke around or in the same house as your child?" ** Otitis media is an infection of the middle ear. Passive smoking promotes adherence of respiratory pathogens to the lining of the middle ear space and prolongs the inflammation and impedes drainage from the ear. Incorrect Answers: A. Otitis media is an infection of the middle ear and is not caused by exposure to cold weather. C. Although aspirin has some implications for Reye's syndrome if taken during a viral illness, aspirin itself does not cause otitis media. D. Although gluten has some association with a variety of gastrointestinal and allergic disorders, it does not cause otitis media.

A nurse is assessing a preschooler who has recurrent and persistent otitis media. When obtaining the child's history from her parent, which of the following questions should the nurse ask? A. "Does your child wear a hat outdoors in cold weather?" B. "Does anyone smoke around or in the same house as your child?" C. "Have you given your child any aspirin recently?" D. "Is your child's diet high in gluten?"

Correct Answer: B. Steatorrhea ** Foul, fatty, frothy stools known as steatorrhea are a manifestation of celiac disease, which is a malabsorption syndrome. Incorrect Answers: A. Children with cystic fibrosis have an elevated sweat chloride. C. Children who have cardiovascular disorders develop clubbing of the fingers and toes due to chronic hypoxemia of the tissues. D. Jaundice results from liver dysfunction, not celiac disease.

A nurse is assessing a school-age child who has celiac disease. Which of the following findings should the nurse expect? A. Elevated sweat chloride B. Steatorrhea C. Clubbing of the fingers D. Jaundice

Correct Answer: C. Thin, frail extremities ** The nurse should identify that thin, frail extremities are related to malnourishment and can indicate child maltreatment. The nurse should investigate this finding further and report the results to the provider. Incorrect Answers: A. Bruising of the right elbow is consistent with horseback riding injuries. B. A dislocated shoulder is consistent with horseback riding injuries. D. Abrasions on the wrists are indications consistent with horseback riding injuries, possibly caused by the reins wrapping around the wrists.

A nurse is assessing a school-age child who reports horseback riding 3 times per week and has injuries reportedly related to a fall from a horse. Which of the following findings should the nurse investigate further as an indication of child maltreatment? A. Bruising of the right elbow B. Dislocated left shoulder revealed by X-ray C. Thin, frail extremities D. Abrasions on both wrists

Correct Answer: A. Abdominal distention ** A VP shunt allows excess cerebrospinal fluid from the ventricles to drain into the peritoneal cavity and be reabsorbed. Abdominal distention can indicate the presence of peritonitis due to the draining cerebral spinal fluid or a postoperative ileus. Incorrect Answers: B. This complication can occur following a cardiac catheterization. It is not associated with the insertion of a VP shunt. C. The inability of the shunt to drain due to a blockage will increase intracranial pressure. This can result in pressure on the oculomotor nerve, which causes dilation of the pupils. D. Frontal bossing can be observed in infants with hydrocephalus. Open cranial sutures allow for excess cerebral spinal fluid to cause head enlargement. Frontal bossing describes the protruding frontal skull bones that can occur in severe cases of hydrocephalus.

A nurse is assessing a school-aged child after a ventriculoperitoneal (VP) shunt replacement. Which of the following findings indicates a complication of this procedure? A. Abdominal distention B. Unequal peripheral pulses C. Pinpoint pupils D. Frontal bossing

Correct Answer: D. Periorbital edema ** Periorbital edema is a manifestation of acute glomerulonephritis. Swelling is usually worse in the mornings and spreads throughout the day to the genitalia, abdomen, and extremities. Incorrect Answers: A. Hypokalemia is not a manifestation of acute glomerulonephritis. B. The blood pressure of a school-aged child who has acute glomerulonephritis can suddenly become dangerously high. C. A reduced urine volume is a manifestation of acute glomerulonephritis.

A nurse is assessing a school-aged child who has acute glomerulonephritis. Which of the following manifestations should the nurse expect? A. Hypokalemia B. Decreased blood pressure C. Increased urine volume D. Periorbital edema

Correct Answer: B. The pulse strength of the child's left popliteal artery site is decreased ** When using the greatest risk framework, the nurse should identify that the greatest risk to the child is a decrease or loss of circulation below the catheter insertion site. This can indicate hemorrhage or a thrombus at the site and can result in neurovascular impairment. Incorrect Answers: A. The nurse should monitor and report the child's level of consciousness following a cardiac catheterization to ensure the effects of the sedation used during the procedure are subsiding. However, there is another finding that is the priority to report. C. The nurse should monitor and report the child's respiratory rate and effort and oxygen saturation, along with other vital signs, to relay information to the provider about the child's hemodynamic status. However, the nurse should identify that the child's respiratory rate is within the expected reference range, and another finding is the priority to report. D. The nurse should monitor and report severe pain so that a prescription can be obtained to manage discomfort. Severe pain can alter the child's msniratony status and.result in increased agitation and movement which raises the risk for bleeding at the site.However, there is another finding that is the priority to report.

A nurse is assessing a school-aged child who is 30 minutes postoperative following a cardiac catheterization using the left femoral artery. Which of the following findings should the nurse identify as the priority to report to the provider? A. The child rouses to verbal stimuli B. The pulse strength of the child's left popliteal artery site is decreased C. The child's respiratory rate is 20/min D. The child rates his pain at the catheter insertion site at a 7 on a scale of 0 to 10

Correct Answer: D. Candidiasis ** Candidiasis (oral thrush) results from the overgrowth of Candida albicans, an opportunistic fungus that commonly infects the oral cavity of clients who have immature or compromised immune systems. Candidiasis appears as a cheesy, white plaque that looks like milk curds on the buccal mucosa and tongue. Thrush is often the initial opportunistic infection in an HIV-positive child who is developing AIDS. Incorrect Answers: A. Koplik spots are oral lesions that indicate rubeola. They are small, irregular spots with a blue/white center that appear on the buccal mucosa opposite the molars in the prodromal stage of measles. B. Peripheral neuropathy can develop as an adverse effect of medications used to treat AIDS; however, it is not an indication of an opportunistic infection. C. A chancre is a red, circumscribed, crusted oral lesion of the lip that is the primary manifestation of syphilis.

A nurse is assessing a toddler who has AIDS. Which of the following findings is an indication of an opportunistic infection? A. Koplik spots B. Peripheral neuropathy c. Chancre D. Candidiasis

Correct Answer: C. Deep, rapid respirations ** This finding is a manifestation of severe dehydration. Other manifestations include weight loss of 10% or more, parched mucus membranes, and tachycardia. Incorrect Answers: A. This finding indicates mild dehydration. A toddler experiencing severe dehydration would exhibit intense thirst. B. This finding indicates mild to moderate dehydration. A toddler experiencing severe dehydration would exhibit a capillary refill of 4 seconds or greater and skin tenting. D. This finding indicates moderate dehydration. A toddler experiencing severe dehydration would exhibit an absence of tears and sunken eyeballs.

A nurse is assessing a toddler who has gastroenteritis. Which of the following findings indicates the toddler is experiencing severe dehydration? A. Slight thirst B. Capillary refill of 3 seconds C. Deep, rapid respirations D. Decreased tear production

Correct Answer: A. Koplik spots Koplik spots are small, irregular oral lesions with a bluish-white center. ** They are characteristic of measles (rubeola). Koplik spots appear about 2 days before the maculopapular rash and are accompanied by fevers, malaise, conjunctivitis, and other cold manifestations. Incorrect Answers: B. Swollen parotid glands are an expected finding in a child who has mumps. C. Strawberry tongue is an expected finding in a child who has scarlet fever. D. Paroxysmal coughing is an expected finding in a child who has pertussis.

A nurse is assessing a toddler who has measles (rubeola). Which of the following findings should the nurse expect? A. Koplik spots B. Parotitis C. Strawberry tongue D. Paroxysmal coughing

Correct Answer: C. FLACC ** The nurse should use the FLACC pain scale to monitor the infant for pain. The FLACC scale monitors facial expression, leg movement, activity, cry, and consolability in children 2 months to 7 years of age. Incorrect Answers: A. The nurse should identify that the FACES pain scale is used for children aged 3 years and older. The scale is composed of 6 cartoon faces that range from smiling to crying with tears. B. The nurse should identify that the CRIES pain scale is used for preterm newborns. CRIES is an acronym for crying, requires increased oxygen, increased vital signs, expression, and sleeplessness. D. The nurse should identify that the Premature Infant Pain Profile (PIPP) is used for preterm newborns.

A nurse is assessing an 18-month-old infant who is postoperative. Which of the following pain scales should the nurse use? A. FACES B. CRIES C. FLACC D. PIPP

Correct Answer: A. The toddler is unable to remove his shoes ** An 18-month-old toddler should be able to remove his or her own shoes, socks, and gloves. The nurse should report this finding to the provider. Incorrect Answers: B. The nurse should identify that a 30-month-old toddler should be able to draw a plus sign. C. The nurse should identify that a 30-month-old toddler should be able to jump off a step or small chair. D. The nurse should identify that an 18-month-old toddler should be able to turn 2 to 3 pages in a book. The child should be able to turn a single page in a book at 24 months of age.

A nurse is assessing an 18-month-old toddler during a well-child examination. Which of the following findings should the nurse report to the provider? A. The toddler is unable to remove his shoes B. The toddler is unable to draw a plus sign C. The toddler is unable to jump off a step D. The toddler is unable to turn 1 page of a book at a time

Correct Answer: B. Lanugo over the back ** The nurse should expect an adolescent who has anorexia nervosa to have lanugo present on the skin as a result of impaired metabolic activity. Other manifestations of anorexia nervosa include hypothermia, hypotension, and dry skin. Incorrect Answers: A. The nurse should expect an adolescent who has anorexia nervosa to have a decreased blood pressure. C. The nurse should expect an adolescent who has anorexia nervosa to have dry skin. D. The nurse should expect an adolescent who has anorexia nervosa to have hypothermia.

A nurse is assessing an adolescent who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect? A. Increased blood pressure B. Lanugo over the back C. Oily skin with acne D. Elevated body temperature

Correct Answer: B. Rigid abdomen ** A rigid abdomen is an expected manifestation of appendicitis. Incorrect Answers: A. Right lower quadrant abdominal pain is an expected manifestation of appendicitis. C. Decreased or absent bowel sounds are an expected manifestation of appendicitis. D. Tachycardia and rapid, shallow breathing are expected manifestations of appendicitis.

A nurse is assessing an adolescent who has appendicitis. Which of the following manifestations should the nurse expect? A. Upper right quadrant abdominal pain B. Rigid abdomen C. Hyperactive bowel sounds D. Bradycardia

Correct Answer: D. Assess for manifestations of circulatory impairment ** The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be open for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the nurse should first assess for circulatory impairment to ensure there is no vascular compromise. Incorrect Answers: A. The nurse should give the adolescent ibuprofen to manage pain; however, there is another action the nurse should take first. B. The nurse should elevate the adolescent's leg on pillows to prevent edema; however, there is another action the nurse should take first. C. The nurse might give the adolescent an ice pack to help with pain; however, there is another action the nurse should take first.

A nurse is assessing an adolescent who has sustained a broken tibia. Following the application of a fiberglass cast, the adolescent reports pain and a tingling feeling in the limb. Which of the following actions should the nurse take first? A. Give the adolescent ibuprofen B. Elevate the adolescent's leg on pillows C. Place an ice pack on the cast D. Assess for manifestations of circulatory impairment

Correct Answer: D. Oxygen saturation ** When using the airway, breathing, and circulation (ABC) lapproach to client care, the nurse should identify that checking the adolescent's oxygen saturation level is the priority. By monitoring the adolescent's oxygen saturation level and respiratory status, the nurse can identify if the client has developed opioid-induced respiratory depression. Incorrect Answers: A. The nurse should assess the adolescent's skin around the catheter site to monitor for bleeding, leakage, or infection. However, there is another assessment the nurse should perform first. B. The nurse should assess the adolescent's blood pressure to monitor for hypotension from the fentanyl and epidural catheter. However, there is another assessment the nurse should perform first. C. The nurse should assess the adolescent's pain level to evaluate effectiveness of the fentanyl. However, there is another assessment the nurse should perform first

A nurse is assessing an adolescent who is receiving fentanyl via epidural. Which of the following assessments should the nurse identify as the priority? A. Skin around the catheter site B. Blood pressure C. Pain level D. Oxygen saturation

Correct Answer: A. Tension pneumothorax ** The nurse should identify these manifestations as an indication the infant is developing a tension pneumothorax. The infant might also become cyanotic and show asymmetry of the thorax. Incorrect Answers: B. These manifestations do not indicate flail chest. Manifestations of flail chest include a pulling of the traumatized rib area inward during inspiration and outward during expiration. C. These manifestations do not indicate a pulmonary contusion. Manifestations of pulmonary contusion include decreased breath sounds, tachycardia, tachypnea, and blood-tinged secretions. D. These manifestations do not indicate a fractured rib. Manifestations of a rib fracture include pain and ecchymosis in the area of trauma, swelling, and muscle spasms.

A nurse is assessing an infant who develops respiratory distress, absence of breath sounds on one side, and deviation of the trachea away from the affected side. Based on these manifestations, which of the following conditions is the infant experiencing? A. Tension pneumothorax B. Flail chest C. Pulmonary contusion D. Fractured rib

Correct Answer: B. Capillary refill 5 seconds ** When using the urgent vs nonurgent approach to client care, the nurse should identify that the priority finding is a capillary refill of 5 seconds. A capillary refill above 4 seconds is an indication of severe dehydration and requires immediate intervention to prevent progression to hypovolemic shock. Incorrect Answers: A. Decreased skin turgor is nonurgent because it is a manifestation of moderate dehydration. Therefore, there is another finding that is the nurse's priority. C. A heart rate of 150/min is nonurgent because it is an expected finding for an infant. Therefore, there is another finding that is the nurse's priority. D. Dry mucous membranes are a nonurgent finding and an early manifestation of mild dehydration. Therefore, there is another finding that is the nurse's priority.

A nurse is assessing an infant who has acute gastroenteritis. Which of the following findings should the nurse identify as the priority? A. Decreased skin turgor B. Capillary refill 5 seconds C. Heart rate 150/min D. Dry mucous membranes

Correct Answer: A. Constipation ** The nurse should expect an infant who has untreated congenital hypothyroidism to exhibit constipation and an enlarged abdomen. Incorrect Answers: B. The nurse should expect an infant who has untreated congenital hypothyroidism to exhibit hyporeflexia and decreased muscle tone. C. The nurse should expect an infant who has untreated congenital hypothyroidism to exhibit dry, scaly skin. D. The nurse should expect an infant who has untreated congenital hypothyroidism to exhibit hypothermia and cool extremities.

A nurse is assessing an infant who has untreated congenital hypothyroidism. Which of the following manifestations should the nurse expect? A. Constipation B. Hyperreflexia C. Oily skin D. Hyperthermia

Correct Answer: A. High-pitched cry ** The nurse should identify that an infant's high-pitched cry is an indication of increased ICP. Other indications include a bulging fontanel, a high-pitched cry, and increased sleeping. Incorrect Answers: B. The nurse should identify that a firm and bulging fontanel is an indication of increased ICP. C. The nurse should identify bradycardia as an indication of increased ICP. D. The nurse should identify increased sleep time as an indication of increased ICP.

A nurse is assessing an infant who is at risk for increased intracranial pressure (ICP). Which of the following findings should indicate to the nurse that this complication is developing? A. High-pitched cry B. Sunken fontanel C. Tachycardia D. Increased awake time

Correct Answer: C. 6 months ** Because the infant was born 8 weeks prematurely, the nurse should use this data to determine that the infant's setback age is 6 months. Therefore, the nurse should expect the infant to have achieved the developmental milestones of a 6-month-old infant. IncorrectAnswers: A. Although the nurse should expect the infant to be developmentally younger than a full-term infant who is now 8 months old, the nurse should expect this infant to be developmentally older than 2 months. B. Although the nurse should expect the infant to be developmentally younger than a full-term infant who is now 8 months old, the nurse should expect this infant to be developmentally older than 4 months. D. The nurse should expect the infant to be developmentally younger than a full-term infant who is now 8 months old.

A nurse is assessing an infant who was born at 32 weeks gestation and is now 8 months old. Which of the following developmental ages should the nurse expect the infant to demonstrate? A. 2 months B, 4 months c. 6 months D. 8 months

Correct Answer: D. FACES Rating Scale ** The nurse should use the FACES rating scale to assess this child's pain level. This scale is appropriate for a 3-year-old and provides a series of facial expressions representing amounts of pain. Incorrect Answers: A. This scale is used to measure pain in children who are ages 4 to 17 years old. B. This tool is used to measure pain in children as young as 4 years old who know how to recognize colors. C. This tool is used to measure pain in children as young as 4 years old who have the cognitive ability to use numbers.

A nurse is assessing pain in a 3-year-old child following a tonsillectomy. Which of the following rating scales should the nurse use to determine the child's pain level? A. Word-Graphic Rating Scale B. Color Tool C. Poker Chip Tool D. FACES Rating Scale

Correct Answer: D. Standing on 1 foot ** The nurse should expect a 3-year-old child to have the gross motor ability to stand on 1 foot for a few seconds. Incorrect Answers: A. Skipping is a developmental task expected of a 4-year-old child. B. Hopping on 1 foot is a developmental task expected of a 4-year-old child. C. Throwing a ball overhead is a developmental task expected of a 4-year-old child.

A nurse is assessing the development of a 3-year-old child. Which of the following gross motor skills should the nurse expect the child to be able to perform? A. Skipping around the room B. Hopping on 1 foot C. Throwing a ball overhead D. Standing on 1 foot

Correct Answer: B. The child has several unexplained scars and bruises. ** The nurse should suspect child maltreatment when the child has multiple unexplained scars and bruises. The nurse should report this finding to the provider. Incorrect Answers: A. Parents providing emotional support to the child is an expected finding. An unexpected finding would be the parents showing no emotion at all toward the child. C. The child's fear of health care staff is an expected finding. An unexpected finding would be the child showing indiscriminate friendliness toward strangers, such as the health care provider. D. Parents offering consistent stories about the child's injuries is an expected finding. An unexpected finding would be the parents presenting conflicting stories about the injury.

A nurse is assessing the dynamics of a family in which child maltreatment is suspected. Which of the following findings should the nurse report to the provider? A. The parents provide emotional support to the child during the assessment process. B. The child has several unexplained scars and bruises. C. The child cries and appears afraid of the health care provider. D. The parents offer consistent, detailed stories about the child's injuries.

Correct Answer: B. Copying a square ** The nurse should expect a 3-year-old child to have the fine motor ability to copy a circle. A 4-year-old child should have the ability to copy a square. Incorrect Answers: A. The nurse should expect a 5-year-old child to have the fine motor ability to tie her shoes. C. The nurse should expect a 5-year-old child to have the fine motor ability to draw a stick figure with 7 to 9 parts. D. The nurse should expect a 5-year-old child to have the fine motor ability to print the letters of her name.

A nurse is assessing the fine motor skill development of a 4-year-old child. The nurse should expect the child to be able to perform which of the following activities? A. Tying shoelaces into a bow B. Copying a square C. Drawing a person with at least 8 parts D. Printing the letters of her name

Correct Answer: D. The preschooler builds a tower of 9 cubes ** The nurse should expect a 3-year-old preschooler to have the fine motors skills needed to build a tower of 9 to 10 blocks. Incorrect Answers: A. The nurse should expect a 5-year-old preschooler to draw a stick figure that has 7 to 9 parts B. The nurse should expect a 5-year-old preschooler to write a few letters or numbers such as her first name. C. The nurse should expect a 4-year-old preschooler to cut out a picture using scissors.

A nurse is assessing the fine motor skills of a 3-year-old preschooler. Which of the following findings should the nurse expect? A. The preschooler can draw a stick figure that has 7 parts B. The preschooler can print her first name C. The preschooler can cut out a picture using scissors D. The preschooler builds a tower of 9 cubes

Correct Answer: B. Standing on 1 foot for several seconds ** Standing on 1 foot for several seconds is an expected behavior for a toddler. Incorrect Answers: A. Walking backward while moving heel to toe is an expected behavior for a 5-year-old child. C. Using scissors to cut out shapes is an expected behavior for a 4-year-old child. D. Printing letters with a pencil is an expected behavior for a 5-year-old child.

A nurse is assessing the gross and fine motor behaviors of a toddler. Which of the following behaviors should the nurse identify as an expected achievement a 3-year-old child? A. Walking backward while moving heel to toe B. Standing on 1 foot for several seconds C. Using scissors to cut out shapes D. Printing letters with a pencil

Correct Answer: A. Hopping on 1 foot ** The nurse should expect a 4-year-old preschooler to hop on 1 foot. Incorrect Answers: B. A 5-year-old preschooler should be able to skip on alternate feet. C. A 5-year-old preschooler should be able to jump rope. D. A 5-year-old preschooler should be able to roller skate.

A nurse is assessing the gross motor skills of a 4-year-old preschooler. The nurse should expect the preschooler to perform which of the following activities? A. Hopping on 1 foot B. Skipping on alternate feet C. Jumping rope D. Roller skating

Correct Answer: C. FACES pain rating scale ** The FACES scale includes various faces, which represent various levels of pain. A 3-year-old child is able to identify faces that represent different pain levels. Incorrect Answers: A. A word graphic rating scale uses a line with words identifying a scale of no pain to the worst possible pain. Children ages 4 to 17 place a line on the scale that describes their pain. Children who are 3 years old will have difficulty understanding this scale. B. The color tool uses 4 markers for the child to represent pain at various levels. Children ages 4 and older can use this tool. Children who are 3 years old might have difficulty remembering what each marker represents. D. Using a numeric scale from 0 to 10 to rate pain requires the child to understand numbers. This tool is helpful for children ages 5 and older.

A nurse is assessing the pain level of a 3-year-old child who is postoperative following abdominal surgery. Which of the following pain scales should the nurse use? A. Word graphic rating scale B. Color tool C. FACES pain rating scale D. Numeric scale

Correct Answer: B. Allow each child to wear his or her glasses during the exam ** The nurse should allow each child to wear his or her glasses during a screening for visual acuity. Incorrect Answers: A. The nurse should position each child so that the heels are at a line that is 3 m (10 ft) away from the Snellen chart C. The nurse should start the screening by testing each child's right eye first. D. The nurse should start the screening by having each child read the 20/20 line of letters on the chart. If they are unable to do so, the nurse should move up to the next larger line of letters on the chart until the child can read at least 4 out of 6 letters correctly.

A nurse is assessing the visual acuity of a group of school-aged children. Which of the following actions should the nurse take? A. Position each child with their heels at a line that is 6 m (20 ft) away from the Snellen chart B. Allow each child to wear his or her glasses during the exam C. Start the screening by covering each child's right eye D. Begin by having each child read the largest line of letters at the top of the Snellen chart

Correct Answer: C. Count respirations before taking other vital signs ** It is best to count the infant's respirations while the infant is calm and before being disturbed. The pulse should be taken next, followed by the temperature, which is the most disruptive assessment to an infant. Incorrect Answers: A. Automated devices are preferred over manual cuffs for measuring an infant's blood pressure because it is difficult to auscultate the beat. B. Apical heart rates, which are heard through a stethoscope held at the apex of the heart, are the most reliable method of determining heart rates. D. Tympanic temperatures do not provide a precise measurement of an infant's body temperature. A rectal temperature is the most consistent with an infant's core temperature.

A nurse is assessing the vital signs of a l-month-old infant. Which of the following actions should the nurse perform? A. Use a cuff to auscultate blood pressure B. Determine heart rate by taking the radial pulse C. Count respirations before taking other vital signs D. Measure temperature by placing the thermometer in the infant's ear

Correct Answer: C. Speech patterns ** Speech patterns are developed through auditory experiences. Chronic otitis media is a common cause of hearing impairment, which can delay the development of speech. Incorrect Answers: A. Besides communication difficulties, complications of otitis media include meningitis, labyrinthitis, and various types of abscesses and thromboses. However, it does not generally affect fine motor skill development. B. Otitis media does not generally affect visual acuity. D. Otitis media does not generally affect hand-to-eye coordination.

A nurse is caring for a 1-year-old infant who has chronic otitis media. The nurse should identify that which of the following areas is at risk of a delay development? A. Fine motor skills B. Visual acuity C. Speech patterns D. Hand-to-eye coordination

Correct Answer: B. 3 oz of baked chicken on a whole-wheat roll ** A baked chicken sandwich on a whole wheat bun has the lowest fat content at 6.2 g. Incorrect Answers: A. A hot dog on a bun contains more than 18.1 g of fat. C. Diced potatoes with scrambled eggs contain 16.5 g of fat. D. A medium blueberry muffin contains 18.2 g of fat.

A nurse is caring for a 10-year-old child who should reduce his fat intake. Which of the following menu choices should the nurse suggest? A, A hot dog on a whole-wheat bun B. 3 oz of baked chicken on a whole-wheat roll C. 1/2 cup of diced potatoes with scrambled eggs D. Medium blueberry muffin

Correct Answer: C. Wear a mask when assisting the toddler with meals. ** The nurse should wear a mask within 3 to 6 feet of the toddler to prevent the transmission of infections that are spread via large-droplet particles expelled in the air. Incorrect Answers: A. A toddler who requires droplet precautions should not play in common areas due to the risk of transmitting the infection. The toddler should wear a surgical mask when being transported through public areas. B. Clean gloves are worn to prevent contact with contaminated body fluids. Urine or stool in the diaper does not carry pathogens that are spread via droplets. D. An N-95 mask is worn when caring for a client who requires airborne precautions.

A nurse is caring for a 15-month-old client who requires droplet precautions. Which of the following actions should the nurse take? A. Have the toddler wear a disposable gown when in the unit's playroom. B. Wear sterile gloves when changing the toddler's diapers. C. Wear a mask when assisting the toddler with meals. D. Ask visitors to wear an N-95 mask when entering the toddler's room.

Correct Answer: A. "Herbal medication can be effective but should be monitored by your provider." ** Herbal medicine may be helpful in relieving menstrual pain. However, there is a risk of toxicity and drug interactions if herbal medicine is taken in the wrong doses or with other medications. The nurse should ask the client if she is using herbal medication and document the dose and effects. Incorrect Answers: B. Dysmenorrhea can result from uterine ischemia and lower abdominal cramping. A cold compress causes vasoconstriction and can increase uterine ischemia. A heating pad or hot bath might provide relief of cramping through muscle relaxation and vasodilation, which can help minimize uterine cramping. C. Exercise helps relieve pain by increasing vasodilation, thereby reducing uterine ischemia, which is a cause of dysmenorrhea. Pelvic rocking is a helpful exercise that the nurse can recommend.

A nurse is caring for a 16-year-old client who reports dysmenorrhea and asks about alternative therapies for treatment. Which of the following statements should the nurse make? A. "Herbal medication can be effective but should be monitored by your provider." B. "You should place a cold compress on your lower abdomen to decrease inflammation." C. "You should limit exercise, which can increase the pain." D. "Avoid touching the painful areas because this can increase your discomfort."

Correct Answer: A. Monitor the infant's head circumference ** Infants with myelomeningocele have an increased risk of hydrocephalus. Measuring the infant's head circumference helps determine any increase of fluid, Incorrect Answers: B. The nurse should place an infant who has myelomeningocele in a prone position to minimize the risk of trauma or tension to the sac. C. The nurse should not place an infant who has myelomeningocele under a radiant warmer because this may dry the lesion and cause cracking. D. Placing a piece of plastic over the protruding membranes will exert pressure on the area. The nurse can place wet gauze over the lesion to provide moisture.

A nurse is caring for a 2-day-old infant who has myelomeningocele. Which of the following actions should the nurse take? A. Monitor the infant's head circumference B. Position the infant supine C. Place the infant under a radiant warmer D. Tape a piece of plastic over the protruding membranes

Correct Answer: D. Building towers with blocks ** Building towers with blocks is an appropriate activity for a 2-year-old child. and promotes fine-motor development. Also, knocking blocks down provides a means of dealing with the stress of hospitalization. Incorrect Answers: A. Most 2-year-old children do not have the coordination abilities to cut with scissors. This activity is appropriate for a 3-year-old child. B. The ability to draw stick figures is an appropriate activity for a 4-year-old child. A 2-year-old child will draw vertical lines and make circular strokes. C. Riding a tricycle is an appropriate activity for a 3-year-old child. Most 2-year-old children do not have the strength or the gross motor ability to ride a tricycle.

A nurse is caring for a 2-year-old child who has cystic fibrosis. The nurse is planning to take the child to the playroom. Which of the following activities would be appropriate for the child? A. Cutting figures from colored paper B. Drawing stick figures using crayons C. Riding a tricycle D. Building towers with blocks

Correct Answer: A. Teach the child to wipe from front to back ** The child should be taught to wipe from front to back in order to prevent bacterial contamination from the anal area entering the urethra. Incorrect Answers: B. The child should avoid bubble baths, which can cause urethral irritation. C. The child should urinate at least every 4 hours to prevent stasis of the urine in the bladder, which can cause bacteria growth. D. Oxybutynin is an antispasmodic used for clients ages 6 and older who have neurogenic bladders.

A nurse is caring for a 2-year-old child who has frequent urinary tract infections. When educating the parents about the prevention of urinary tract infections, which of the following instructions should the nurse include? A. Teach the child to wipe from front to back B. Give the child frequent bubble baths c. Urge the child to urinate every 6 hr D. Administer oxybutynin daily

Correct Answer: B. Coloring book and crayons ** Preschoolers have increasing fine motor control and imagination. They enjoy toys that allow creativity and self-expression. Incorrect Answers: A. A 3-year-old child does not have the physical coordination to use a jump rope. This choice is appropriate for a 5-year-old child. C. A 3-year-old child might be able to play a game with simple rules. However, a game of checkers would not be appropriate due to the complex nature of the game. This choice would be appropriate for a child who is 6 years or older. D. This toy would be an appropriate choice for an infant. A preschooler would quickly become bored with this toy.

A nurse is caring for a 3-year-old child on a pediatric unit. The nurse should identify which of the following as an appropriate toy for the child? A. Jump rope B. Coloring book and crayons C. Checkers game D. Jack-in-the-box

Correct Answer: B. Knee-chest ** The knee-chest position, which is similar to squatting, facilitates the oxygenation of the lungs. The nurse should assist the child into this position to facilitate breathing. Incorrect Answers: A. Orthopneic positioning is not likely to help a child who has a cardiac defect and is having difficulty breathing. However, it can help clients who have respiratory difficulties. C. Sims' position is not likely to help a child who has a cardiac defect and is having difficulty breathing. It is generally used when exposure of the rectal area is required. D. Semi-Fowler's position does promote lung expansion, but this client's difficulty is cardiac in nature, not respiratory.

A nurse is caring for a 3-year-old child who has a cyanotic cardiac defect. The child cries when her parents leave the room, worsening her cyanosis and dyspnea. Into which of the following positions should the nurse place the child to improve these manifestations? A. Orthopneic B. Knee-chest C. Sims' D. Semi-Fowler's

Correct Answer: C. Amoxicillin ** A child who has acute otitis media should take an antibiotic to help alleviate the infection. Incorrect Answers: A. Diphenhydramine is an antihistamine used for allergic reactions. B. Furosemide is a diuretic used to decrease edema. D. Children who are <6 months old should not take ibuprofen. Acetaminophen is the preferred choice for children of this age.

A nurse is caring for a 4-month-old child who has acute otitis media and a fever of 38.3°C (101°F). Which of the following medications should the administer? A. Diphenhydramine B. Furosemide C. Amoxicillin D. Ibuprofen

Correct Answer: C. A plastic mirror ** A 4-month-old infant can recognize herself and will also attempt to play with "the baby in the mirror." A mirror is a bright object that provides appropriate visual stimulation for this age group. For the infant's safety, however, the mirror must be unbreakable. Incorrect Answers: A. This would be an appropriate choice for a 6- to 12-month-old infant. A 4-month-old infant cannot understand the pictures on a board book or hold the book by herself. B. This would be an appropriate choice for a 6- to 12-month-old infant. A 4-month-old infant would not be able to manipulate the toy's movable parts. D. This is an appropriate toy for a 9- to 12-month-old infant. A 4-month-old infant would not be able to perform the actions of pushing and pulling the toy.

A nurse is caring for a 4-month-old child who is hospitalized. Which of the following toys should the nurse provide for the child? A. A board book with large pictures B. A toy with movable parts C.A plastic mirror D. Push-pull toy

Correct Answer: A. Place the infant in knee-chest position ** The nurse should identify that a hypercyanotic spell occurs when a vascular spasm reduces pulmonary blood flow and forces blood to shunt from the right ventricle to the left ventricle through the ventricular septal defect. The nurse should place the infant in a knee-chest position to increase systemic vascular resistance, which will help force more blood through the pulmonary artery. Incorrect Answers: B. The nurse should identify that a hypercyanotic spell is a temporary period of hypoxia that can occur in response to crying, feeding, or straining during a bowel movement. The nurse should not initiate CPR because the infant is still breathing and has a pulse. C. The nurse should administer 100% oxygen via facemask to treat the hypoxia that occurs during a hypercyanotic spell. D. The nurse should not administer adenosine to an infant experiencing a hypercyanotic spell. Adenosine is an antiarrhythmic used in the treatment of supraventricular tachycardia.

A nurse is caring for a 4-month-old infant who has tetralogy of Fallot and experiences a hypercyanotic spell. Which of the following actions should the nurse take? A. Place the infant in knee-chest position B. Begin CPR C. Prepare to intubate the infant D. Administer IV adenosine

Correct Answer: B. The infant has a total bilirubin level of 0.3 mg/dL. ** A bilirubin level of 0.3 mg/dL is within the expected reference range and indicates the surgery was successful. Incorrect Answers: A. Weight loss is an indication that the surgery was not successful. The infant should gain weight following the surgery due to improved intestinal absorption. C. An AST level of 120 units/L is above the expected reference range and indicates continued biliary obstruction. D. If the surgical correction was successful, the infant's stools should turn yellow and then brown in color. Gray stools indicate continued biliary obstruction.

A nurse is caring for a 4-week-old infant who is 2 weeks postoperative following surgical correction of biliary atresia. Which of the following findings is an indication that the surgery was successful? A. The infant has lost 2.2 kg (1 lb) since the surgery. B. The infant has a total bilirubin level of 0.3 mg/dL. C. The infant has an aspartate aminotransferase (AST) level of 120 units/L. D. The infant's stools are gray in color.

Correct Answer: B. Inactivity and thumb sucking ** A child who is sucking his thumb and refusing to eat or drink is displaying manifestations of the second stage of separation anxiety, which despair. Incorrect Answers: A. Protest is the first stage of separation anxiety, which includes crying and screaming. C. Denial or detachment is the third stage of separation anxiety, in which the child appears happy and interacts with strangers. D. Protest is the first stage of separation anxiety, which includes attempting to escape the area to find a parent.

A nurse is caring for a 4-year-old child who has pneumonia. The child's mother left 2 hours ago, and he is currently experiencing the separation anxiety stage of despair. Which of the following findings should the nurse expect? A. Crying and screaming B. Inactivity and thumb sucking C. Showing interest in nearby toys D. Attempting to escape and find the parent

Correct Answer: B. Supplement the child's feedings with enteral feedings ** A child who has burns in excess of 25% of total body surface area requires enteral supplementation to consume enough calories to heal. Incorrect Answers: A. Children who have cystic fibrosis require pancrelipase, a pancreatic enzyme to aid in digestion. Children who have cystic fibrosis are unable to digest without this medication. C. Superficial partial-thickness burns affect both the outer and underlying layers of the skin, causing pain, redness, swelling, and blistering. A child who has a burn needs a high-carbohydrate and high-protein diet with adequate fat for healing. D. Dressing changes are painful, so they should not be done prior to feedings since appetite and digestion might be negatively affected.

A nurse is caring for a 4-year-old child who has superficial partial-thickness burns over 50% of his body. To meet the nutritional needs of the child, which of the following actions should the nurse plan to take? A. Administer pancrelipase to the child prior to each meal B. Supplement the child's feedings with enteral feedings C. Provide the child with a low-protein meal D. Perform dressing changes 10 min prior to the child's meals

Correct Answer: D. Place the child in a side-lying position ** The nurse should place the child in a side-lying position to facilitate drainage of oral secretions, which decreases the risk of aspiration. Incorrect Answers: A. The nurse should not administer oral acetaminophen during the postictal phase of a seizure because the child could aspirate the medication. B. The nurse should not sponge the child's skin with cold water or rubbing alcohol because this can cause shivering, which will further increase the body temperature. C. The nurse should administer rectal diazepam if the seizure lasts longer than 5 minutes.

A nurse is caring for a 5-year-old child who has a fever and begins to have a seizure. Which of the following actions should the nurse take? A. Give acetaminophen 240 mg PO immediately following the seizure B. Sponge the child's skin with a mixture of cold water and rubbing alcohol C. Administer rectal diazepam if the seizure lasts longer than 2 minutes D. Place the child in a side-lying position

Correct Answer: C. Prepare the child for a barium enema ** The pressure created by a barium enema might force the bowel to resume a normal configuration. Some children with intussusception are treated with the barium enema and do not require surgical intervention. Incorrect Answers: A. Intussusception is not an inflammatory process but a mechanical obstruction. B. Abdominal pain observed with intussusception is a contraindication for receiving magnesium hydroxide, a laxative. In addition, children with this condition are NPO and should not receive anything by mouth. D. During surgical intervention, the provider will remove the nonviable portion of the bowel so the bowel is anastomosed; there is no need for a colostomy.

A nurse is caring for a 6-month-old infant who has intussusception. Which of the following actions should the nurse take? A. Prepare to administer high-dose steroids B. Give the child magnesium hydroxide PO C. Prepare the child for a barium enema D. Inform the parents that the child will need a colostomy

Correct Answer: B. Small, frequent bottle feedings of electrolyte solution ** Feedings begin 4 to 6 hours after the surgical procedure. The nurse should anticipate feeding the infant small, frequent increments of an electrolyte solution or sterile water. Incorrect Answers: A. Small, incremental formula feedings will resume 24 hours after surgery if small frequent feedings of electrolyte solution are retained by the infant. C. Nasoduodenal tube feedings are indicated for children who have brain injuries or are on mechanical ventilation. D. Gastrostomy feedings are indicated for children who cannot have any foods or fluid by mouth or for whom the passage of a tube through the esophagus is contraindicated.

A nurse is caring for a 6-week-old infant following a pyloromyotomy. Which of the following forms of feeding should the nurse anticipate for the infant 6 hr after the procedure? A. Bottle formula with added protein B. Small, frequent bottle feedings of electrolyte solution C. Continuous nasoduodenal tube feedings D. Bolus feedings via gastrostomy tube

Correct Answer: C. Determine if there are any recent stressors in the child's environment ** Encopresis can be caused by stress or changes in the child's environment. Incorrect Answers: A. Treatment for encopresis includes emptying the bowel of impacted stool, followed by the administration of daily stool softeners for 2 to 3 months. B. The nurse should encourage the child to attempt to have a bowel movement twice daily. This will help the child establish a regular pattern of defecation, D. The guardian should pay as little attention as possible to bowel accidents and offer praise when encopresis does not occur.

A nurse is caring for a 6-year-old child who is experiencing encopresis. Which of the following actions should the nurse take? A. Instruct the child's guardian to limit stool softener use to no more than twice per week B. Encourage the child to attempt to have a bowel movement 4 times per day C. Determine if there are any recent stressors in the child's environment D. Urge the child's guardian to provide negative consequences when the child has a bowel accident

Correct Answer: D. Chapter books **The nurse should offer chapter books as an appropriate diversional activity for a school-age child who has limited movement due to skeletal traction. Incorrect Answers: A. The nurse should offer a puzzle with large pieces as a diversional activity for a preschooler. B. The nurse should offer building blocks as a diversional activity for a preschooler. C. Although school-age children enjoy crafts such as painting, finger painting is a diversional activity the nurse should offer a toddler.

A nurse is caring for a 7-year-old child who is in skeletal traction following complete fracture of the femur. Which of the following diversional activities should the nurse offer the child? A. Puzzle with large pieces B. Building blocks C. Finger paints D. Chapter books

Correct Answer: B. Semi-Fowler's ** Maintaining a semi-Fowler's position promotes adequate ventilation. Flexing the knees slightly will likely be the most comfortable position for the child. Additionally, this promotes drainage of the cecum downward into the pelvis instead of upward toward the lungs. Incorrect Answers: A. Maintaining a supine position will not promote adequate ventilation and can cause painful tugging on or stretching of the incisional area. C. Maintaining Sims' position will not promote adequate ventilation, and the degree of flexion required by the upper leg can cause painful compression of the incisional area. D. This position is used for clients who have difficulty breathing and can cause painful pressure on or compression of this client's incisional area.

A nurse is caring for a child who has a ruptured appendix. Which of the following positions should the nurse encourage the child to maintain? A. Supine B. Semi-Fowler's C. Sims' D. Orthopneic

Correct Answer: B. Remove the catheter while applying intermittent suction ** The nurse should insert the catheter without suction and then withdraw the catheter while applying intermittent suction. Incorrect Answers: A. The nurse should insert the catheter 0.5 cm (0.2 in) beyond the end of the tracheostomy tube. C. The nurse should avoid the routine instillation of 0.9% sodium chloride irrigation for suctioning. D. The nurse should limit suctioning to no more than 3 aspirations at a time.

A nurse is caring for a child who has a tracheostomy. Which of the following techniques should the nurse use to suction the child's tracheostomy? A. Insert the catheter to 2 cm (0.79 in) beyond the end of the tracheostomy tube B. Remove the catheter while applying intermittent suction C. Instill 0.9% sodium chloride irrigation to loosen secretions while suctioning D. Continue suctioning until the secretions are removed

Correct Answer: B. Check the child's blood pressure every 4 hr ** The nurse should check the child's blood pressure every 4 to 6 hours to monitor for hypertension. Incorrect Answers: A. Glomerulonephritis does not require strict bed rest because ambulation does not affect the disease. However, a child might experience fatigue with glomerulonephritis and can voluntarily restrict activities when the disease is most active. C. A child who has nephrotic syndrome might require albumin to correct hypoalbuminemia and extreme edema. Administering albumin causes serum albumin levels to rise and prompts fluid shifts from the subcutaneous spaces into the bloodstream, which decreases edema. A child who has glomerulonephritis has mild edema, so albumin is not needed. D. A child who has glomerulonephritis should have limited sodium intake, but there is no restriction on carbohydrate consumption.

A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions should A. Maintain the child on strict bed rest B. Check the child's blood pressure every 4 hr C. Administer albumin to the child every 8 hr D. Provide the child with a low-carbohydrate diet

Correct Answer: B. Oxygen saturation 85% ** The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the nurse should report this finding to the provider immediately. Incorrect Answers: A. A blood glucose level of 140 mg/dL is above the expected reference range and might require intervention; however, this finding does not need to be reported to the provider immediately. C. An RBC of 3.2 million/ul is below the expected reference range and might require intervention; however, this finding does not need to be reported to the provider immediately. D. A serum sodium level of 156 mEq/Lis above the expected reference range and might require intervention; however, this finding does need to be reported to the provider immediately.

A nurse is caring for a child who has an exacerbation of cystic fibrosis. Which of the following laboratory findings should the nurse report to the provider immediately? A. Blood glucose 140 mg/dL B. Oxygen saturation 85% C. RBC 3.2 million/ul D. Serum sodium 156 mEq/L

Correct Answer: A. "The PICC line will last for several weeks with proper care." ** A PICC line is the preferred venous access device for short- to moderate-term IV therapy. It can remain in place for long periods with proper care. Incorrect Answers: B. A PICC line is meant to remain in place for the duration of therapy. This is its main advantage over a traditional IV and why it is the preferred venous access device for moderate-term IV therapy, such as the extended antibiotic therapy required for bacterial endocarditis. C. The catheters designed for use as PICC lines are highly flexible, so it is not necessary to immobilize the client's arm or limit movement. D. PICC lines are inserted using a local anesthetic by trained personnel.

A nurse is caring for a child who has bacterial endocarditis. The child is scheduled to receive moderate-term antibiotic therapy and requires a peripherally inserted central catheter (PICC). Which of the following statements should the nurse include when teaching the child's parent? A. "The PICC line will last for several weeks with proper care." B. "The public health nurse will rotate the insertion site every 3 days." C. "You will need to ensure the arm board is in place at all times." D. "Your child will go to the operating room to have the line placed."

Correct Answer: B. Check for pulses in the affected leg every 4 hr ** Traction might lead to neurovascular compromise. The nurse should assess for edema, pulses, pain, color, and temperature of the extremity every 4 hours. Incorrect Answers: A. The nurse should not move or adjust the weight to ensure proper alignment and correct healing. C. Buck's traction is skin traction, which works without the use of pins. D. A child who is in Buck's traction is not ill and should be encouraged to continue socialization through various means.

A nurse is caring for a child who has been in Buck's traction for 2 days. Which of the following actions should the nurse take to prevent complications? A. Manually move the weights to the floor when the child is experiencing pain B. Check for pulses in the affected leg every 4 hr c. Cleanse the pins every 12 hr D. Inform parents to discourage visitors for the child

Correct Answer: A. Dark urine ** Dark urine can be an indication of myoglobinuria. It results from the elimination of waste products from muscle damage and can cause renal failure. Incorrect Answers: B. Radial pulses of +2 are within the expected reference range. They are a reflection of circulatory status, not burn complications. C. A respiratory rate of 20/min is within the expected reference range. It reflects respiratory status, not burn complications. D. Electrical injuries can cause major, full-thickness burns that destroy the nerve endings in the skin, thus reducing the amount of pain the client feels.

A nurse is caring for a child who has electrical burns on the lower arms and hands. Which of the following findings indicate the child is experiencing a complication of the injury? A. Dark urine B. 2+ radial pulses C. Respiratory rate of 20/min D. Minimal pain

Correct Answer: C. Apply continuous pressure to the child's nose for at least 10 min ** The nurse needs to apply continuous pressure for at least 10 minutes to help stop bleeding. Incorrect Answers: A. Applying a warm cloth to the bridge of the nose causes vasodilation, which can increase bleeding. B. Tilting the head back allows blood to flow down the back of the throat, which can cause nausea. D. Aspirin can increase bleeding from the site due to its antithrombotic actions. The use of aspirin is contraindicated in children.

A nurse is caring for a child who has epistaxis. Which of the following actions should the nurse perform? A. Apply a warm cloth to the bridge of the child's nose B. Tilt the child's head back C. Apply continuous pressure to the child's nose for at least 10 min D. Administer aspirin for the child's pain

Correct Answer: D. Apply continuous pressure to the lower part of the child's nose ** With the child sitting up and breathing through the mouth, the nurse should apply continuous pressure with the thumb and forefinger to the soft lower area of the nose for 10 minutes. Most bleeding from the nose stops within this period. Incorrect Answers: A. Aspirin can increase bleeding from the site due to its antithrombotic actions. B. Tilting the head back allows blood to flow down the back of the throat, causing nausea. C. Lying down increases the risk of aspirating blood.

A nurse is caring for a child who has epistaxis. Which of the following actions should the nurse take? A. Administer aspirin B. Tilt the child's head back and apply pressure C. Have the child lie down and rest D. Apply continuous pressure to the lower part of the child's nose

Correct Answer: C. Weigh the child once each day ** The nurse should weigh the child at the same time each day to monitor fluid balance. Incorrect Answers: A. Glomerulonephritis can cause hypertension that can lead to cerebral ischemia. Therefore, the nurse should monitor the child's blood pressure every 4 hours. B. The child should participate in activities as tolerated. Bed rest is not required. D. The nurse should offer the child a regular diet with moderate sodium restriction and ensure no salt is added to foods.

A nurse is caring for a child who has glomerulonephritis. Which of the following actions should the nurse take? A. Monitor the child's blood pressure twice per day B. Maintain the child on bed rest for 3 days C. Weigh the child once each day D. Increase the child's daily intake of sodium

Correct Answer: B. Administer oral analgesics prior to exercises ** Paralytic poliomyelitis presents with pain and stiffness in the back, neck, and legs followed by signs of central nervous system paralysis. Range-of-motion exercises are necessary to prevent contractures, but they can cause the child discomfort. Incorrect Answers: A. The nurse should implement contact precautions for a client with poliomyelitis. This virus is spread by direct contact with feces and oropharyngeal secretions. C. Respiratory complications from poliomyelitis are due to paralysis of the respiratory muscles. The nurse should assess the child for signs of weak respiratory effort such as difficulty talking, ineffective coughing, and shallow and rapid respirations. D. Seizures are not an expected complication of a poliomyelitis infection.

A nurse is caring for a child who has paralytic poliomyelitis. Which of the following actions should the nurse take? A. Implement droplet precautions B. Administer oral analgesics prior to exercises c. Use humidified oxygen to thin secretions D. Initiate seizure precautions

Correct Answer: A. Administer ibuprofen ** The nurse should administer ibuprofen or acetaminophen for mild to moderate pain. If pain is not relieved, the nurse should administer an opioid analgesic. Incorrect Answers: B. The nurse should encourage the child to increase daily fluid intake to reduce blood viscosity and prevent sickling of red blood cells. C. Cold compresses increase vasoconstriction and increase pain. Therefore, the nurse should apply warm compresses to painful joints. D. The nurse should ensure the child receives all immunizations to prevent infection. Infection is a major cause of death in children who have sickle cell anemia.

A nurse is caring for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following actions should the nurse take? A. Administer ibuprofen B. Limit daily fluid intake C. Apply cold compresses to painful joints D. Withhold live virus immunizations

Correct Answer: D. Serum cholesterol 700 mg/dL ** A serum cholesterol level of 700 mg/dL is above the expected reference range. A child who has nephrotic syndrome will have high serum cholesterol findings because of the increase in plasma lipids. Incorrect Answers: A. A platelet count of 120,000/mm^3 is below the expected reference range. Children with nephrotic syndrome have an increased platelet count because of hemoconcentration. B. A serum sodium level of 160 mEg/L is above the expected reference range. Children who have nephrotic syndrome have a serum sodium level that is lower than expected because of hemoconcentration. C. A hemoglobin level of 9 g/dL is below the expected reference range. Children who have nephrotic syndrome will have hemoglobin levels that are within the expected reference range or elevated.

A nurse is caring for a child who has suspected nephrotic syndrome. Which of the following laboratory values should the nurse expect? A. Platelets 120,000/mm^3 B. Serum sodium 160 mEg/L C. Hgb 9 g/dL D. Serum cholesterol 700 mg/dL

Correct Answer: D. RBC 6.8 million/uL ** A child who has tetralogy of Fallot experiences cyanosis; therefore, the body responds by increasing RBC production (polycythemia) in an attempt to supply oxygen to all body parts. Incorrect Answers: A. A platelet count of 20,000/mm^3 is below the expected range. A child who has tetralogy of Fallot will not have a decreased platelet count. B. A WBC count of 4,000/mm^3 is below the expected reference range. A child who has tetralogy of Fallot will not have neutropenia. C. This hormone level is above the expected reference range. A child who has tetralogy of Fallot will not have changes in thyroid function levels.

A nurse is caring for a child who has tetralogy of Fallot. Which of the following laboratory values should the nurse expect to find? A. Platelet count of 20,000/mm^3 B. WBC 4,000/mm^3 C. Thyroid stimulating hormone 7.0 microunits/mL D. RBC 6.8 million/ul

Correct Answer: D. Encourage the child to use an incentive spirometer ** The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Encouraging the child to use an incentive spirometer will promote adequate oxygenation and is the priority nursing action. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Incorrect Answers: A. The nurse should perform passive range of motion for unaffected joints; however, a different action is the nurse's priority. B. The nurse should massage the child's pressure areas; however, a different action is the nurse's priority. C. The nurse should increase the child's fluid intake; however, a different action is the nurse's priority.

A nurse is caring for a child who is in skeletal traction. Which of the following actions is the nurse's priority? A. Perform passive range of motion for unaffected joints B. Massage the child's pressure areas C. Increase the child's fluid intake D. Encourage the child to use an incentive spirometer

Correct Answer: B. Acetylcysteine ** Acetylcysteine is the antidote for acetaminophen overdose or poisoning. Incorrect Answers: A. Digoxin immune fab is an antidote for digoxin toxicity. C. Naloxone is the antidote for opioid overdose. D. Children who have salicylate (aspirin) poisoning or overdose should receive vitamin K to decrease bleeding.

A nurse is caring for a child who is in the emergency department after ingesting a bottle of acetaminophen. Which of the following medications should nurse plan to administer? A, Digoxin immune fab B. Acetylcysteine C. Naloxone D. Vitamin K

Correct Answer: C. Frequent swallowing ** When applying the urgent versus non-urgent priority-setting framework, the nurse should consider urgent needs to be the priority because they pose more of a threat to the client. Frequent swallowing can be an indication of bleeding and must be addressed. The nurse may also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which finding is the most urgent. Incorrect Answers: A. Nausea is a common adverse effect of anesthesia; therefore, this is not the nurse's priority. B. A hoarse voice is an expected finding following a tonsillectomy; therefore, this is not the nurse's priority. D. A sore throat is an expected finding following a tonsillectomy; therefore, this is not the nurse's priority.

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following findings is the nurse's priority? A. Nausea B. Hoarse voice C. Frequent swallowing D. Sore throat

Correct Answer: A. Administer 5% dextrose in 0.9% sodium chloride by continuous IV infusion ** When the child's blood glucose level falls between 250 and 300 mg/dL, the nurse should begin IV infusion of 5% or 10% dextrose in 0.9% sodium chloride. The goal is to maintain blood glucose levels between 120 and 240 mg/dL. If dextrose is not added, hypoglycemia might occur, Incorrect Answers: B. Giving potassium as a rapid IV bolus is contraindicated because it can result in cardiac arrest. C. Ultralente is long-acting insulin that takes 6 to 14 hours to begin working. Regular insulin will be given via IV infusion until the blood sugar reaches 250 to 300 mg/dL. If the regular insulin infusion continues, hypoglycemia can occur. D. An HbAlc level measures the blood glucose level over the last 2 to 3 months and will not give useful information about the client's current status.

A nurse is caring for a child who is receiving treatment for diabetic ketoacidosis and has a current blood glucose level of 250mg/dL. Which of the following actions should the nurse take? A. Administer 5% dextrose in 0.9% sodium chloride by continuous IV infusion B. Give potassium as a rapid IV bolus C. Administer 3 units of ultralente insulin subcutaneously D. Obtain an HbAlc level stat

Correct Answer: B. Assess for laryngeal edema ** The greatest risk to this child is bronchoconstriction due to an anaphylactic reaction to penicillin. Therefore, the first action the nurse should take is to assess the child for laryngeal edema and implement interventions to maintain a patent airway. Incorrect Answers: A. The nurse should administer an antihistamine such as diphenhydramine to treat the anaphylactic reaction to penicillin. However, there is another actio enurse should take first. C. The nurse should frequently monitor the child's urine output to determine the effects of the anaphylactic reaction. However, there is another action the nurse should take first. D. The nurse should administer epinephrine to treat the anaphylactic reaction to penicillin. However, there is another action the nurse should take first.

A nurse is caring for a child who received penicillin IM 15 minutes ago. The child is now irritable and restless. Which of the following actions should the nurse take first? A. Administer diphenhydramine B. Assess for laryngeal edema C. Initiate hourly urine output monitoring D. Give epinephrine IV push

Correct Answer: D. Varicella ** Children who have varicella may present first with a maculopapular rash that progresses to vesicles on erythematous bases, which eventually rupture and crust over. Incorrect Answers: A. A child who has measles might develop Koplik spots, a transient cephalocaudal rash of maculopapular eruptions of the upper trunk and face. The rash becomes more confluent as it spreads to the lower areas of the body. B. Fifth disease usually begins with bright red cheeks, producing a "slapped-cheek" appearance. Then, a rash appears on the extremities and trunk. The rash fades centrally, giving a lacy (reticulated) appearance. C. A child who has tetanus will develop lockjaw and muscle rigidity; however, there is no rash associated with tetanus. The DTAP immunization aids the prevention of this disease.

A nurse is caring for a child with a vesicular rash that has been present for 6 days. The nurse should expect that the child has which of the following conditions? A. Measles B. Fifth disease C. Tetanus D. Varicella

Correct Answer: D. Inability to clear secretions ** The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the inability to clear secretions is the priority-finding because the child has a compromised airway; the nurse must act in a manner that ensures transportation of oxygen to the body's cells. Incorrect Answers: A. Blood streaking of the sputum is a common finding in children who have cystic fibrosis and a pulmonary infection; therefore, this is not the nurse's priority. B. Children who have cystic fibrosis might have dry mucous membranes due to malabsorption of sodium and chloride, which results in dehydration; this is not the nurse's priority. C. Constipation is common in children who have cystic fibrosis because of malabsorption of sodium and chloride, resulting in dehydration; this is not the nurse's priority.

A nurse is caring for a child with cystic fibrosis who has a pulmonary infection. Which of the following findings is the nurse's priority? A. Blood streaking of the sputum B. Dry mucous membranes C. Constipation D. Inability to clear secretions

Correct Answer: A. "I have bowel movements every 4 to 5 days." ** The nurse should identify that this frequency of UTIS indicates the adolescent is constipated. Therefore, large stool masses might prevent complete emptying of the bladder and lead to urinary stasis and infection. Incorrect Answers: B. The adolescent will improve perineal hygiene by wiping from front to back, which decreases the likelihood of a UTI. C. Emptying the bladder every 2 to 3 hours prevents urinary stasis and infection. D. The adolescent should wear cotton underwear to help prevent UTIS, as nylon underwear is more likely to trap bacteria in the genital area of a female client.

A nurse is caring for a female adolescent who is being treated for frequent urinary tract infections (UTIS). Which of the following statements by the adolescent indicates a possible cause of the UTIS? A. "I have bowel movements every 4 to 5 days." B. "My mom taught me to wipe from front to back after going to the bathroom." C. "I urinate every 2 to 3 hr during the day." D. "I don't wear nylon underwear."

Correct Answer: A. Transposition of the great arteries ** An infant who has transposition of the great arteries will have severe cyanosis because reversal of the anatomical position of the aorta and pulmonary artery allows venous blood to enter the systemic circulation without oxygenation. Incorrect Answers: B. An infant who has a ventricular septal defect (a hole in the septal wall between the ventricles) can have increased pulmonary vascular resistance but is unlikely to have cyanosis because oxygenation of the blood remains adequate for systemic circulation. C. An infant who has coarctation of the aorta (constricted segment of the aorta that obstructs blood flow to the body) is unlikely to have cyanosis. Even though the left ventricle must generate higher than normal pressures for adequate stroke volume, oxygenation of the blood remains adequate for the systemic circulation. D. An infant who has a patent ductus arteriosus will have a blood vessel connecting the pulmonary artery to the aorta. The infant can have increased pulmonary vascular resistance, but oxygenation of the blood remains adequate for systemic circulation.

A nurse is caring for a group of infants with congenital heart defects. For which of the following defects should the nurse expect to observe cyanosis? A. Transposition of the great arteries B. Ventricular septal defect c. Coarctation of the aorta D. Patent ductus arteriosus

Correct Answer: B. Encourage the parents to touch and care for the newborn ** Touching and caretaking will help the parents bond with the newborn. Incorrect Answers: A. A newborn who has spina bifida can typically be cared for in the home with proper education of the parents and other caregivers. C. Encouraging the parents to resolve their grief as soon as possible is not appropriate. The family should be allowed time to grieve. D. Avoidance of the subject can discourage the parents from bringing up issues they want to discuss.

A nurse is caring for a newborn who has spina bifida. The newborn's parents are upset by the diagnosis. Which of the following actions should the nurse take? A. Discuss placement options for the newborn B. Encourage the parents to touch and care for the newborn C. Reassure the parents that everything will be fine D. Avoid talking about the newborn's defect until the parents bring up the subject

Correct Answer: B. Instruct the child to use a soft-sponge toothbrush when brushing her teeth. ** The child should use a soft-sponge toothbrush when brushing her teeth because a regular toothbrush may cause further irritation to the mucosal ulcers. Incorrect Answers: A. Preschool-age children should not take viscous lidocaine because it depresses the gag reflex, increasing their risk of aspiration. C. Children who have mucosal ulcers should not use hydrogen peroxide as a mouth rinse because the drying effects on the mucosa may cause further ulceration. D. Children who have mucosal ulcerations should avoid using lemon glycerin swabs because they are irritating, especially on eroded tissues.

A nurse is caring for a preschool-age child who has mucosal ulceration after receiving chemotherapy. Which of the following actions should the nurse take? A. Place viscous lidocaine on the child's oral lesions. B. Instruct the child to use a soft-sponge toothbrush when brushing her teeth. C. Encourage the child to rinse her mouth with hydrogen peroxide every 2-4 hr. D. Give the child lemon glycerin swabs to use after each meal.

Correct Answers: A. The child views death as similar to sleep. D. The child believes his thoughts can cause death. E. The child thinks death is a punishment. ** Preschool-age children may think of death like sleep. Preschool-age children also believe that their thoughts and wishes can make things happen since they are egocentric. This is part of why the death of a family member can be difficult for a child at this age. Finally, preschool- age children sometimes believe that death is the result of guilt or a punishment for something they did, said, or thought. Incorrect Answers: B. A school-age child will be interested in post-death services and what happens to the body after death due to an improved ability to comprehend what is happening.

A nurse is caring for a preschool-age child who is dying. Which of the following findings is an age-appropriate reaction to death by the child? (Select all that apply.) A. The child views death as similar to sleep. B. The child is interested in what happens to the body after death. C. The child recognizes that death is permanent. D. The child believes his thoughts can cause death. E. The child thinks death is a punishment.

Correct Answer: A. Believes that her own thoughts can cause death ** The nurse should expect preschoolers to believe that their own thoughts or actions can cause death, and they might believe that death is a punishment for wrong-doing. Incorrect Answers: B. The nurse should expect a preschooler to view death as a temporary occurrence like sleeping. The preschooler might believe the person can "wake up" again. C. The nurse should expect a school-aged child to be curious about what happens to a body following death. D. The nurse should expect an adolescent to reject traditions surrounding death such as funeral services as unnecessary or unimportant.

A nurse is caring for a preschooler who has a terminal illness. The nurse should expect the preschooler to have which of the following perspectives about death? A. Believes that her own thoughts can cause death B. Has an understanding of the finality of death C. Exhibits curiosity about what happens to the body after death D. Views funeral services as unnecessary

Correct Answer: C. Monitor the child's temperature every 30 minutes ** The nurse should monitor the child's temperature every 15 to 30 minutes. Surgery on the brainstem can cause hyperthermia. Incorrect Answers: A. The nurse should have the child avoid coughing because this can increase intracranial pressure. B. The nurse should not offer the child clear liquids for at least 24 hours following the procedure. The gag and swallow reflexes are frequently depressed, increasing the risk of aspiration. D. The nurse should not place the child in the Trendelenburg position because it increases intracranial pressure and raises the risk of postoperative hemorrhage.

A nurse is caring for a preschooler who is immediately postoperative following the removal of a brainstem tumor. Which of the following actions should the nurse take? A. Have the child deep-breathe and cough every hour B. Offer the child clear liquids 4 hours after the procedure C. Monitor the child's temperature every 30 minutes D. Place the child in Trendelenburg position

Correct Answers: A. Apply a topical antibacterial ointment to the lesions B. Wash the child's bed linens daily with hot water E. Wash hands before and after contact with the affected area ** Impetigo contagiosa is a bacterial infection of the skin. Therefore, the nurse should plan on teaching the child's parents about topical application of an antibacterial ointment. The parents should wash their hands before and after contact with the affected area and wash the child's bed linens daily in hot water to decrease the risk of reinfection or transmission.

A nurse is caring for a preschooler who was brought to an outpatient clinic with a 2-day history of a vesicular, honey-colored crusty region around the nose and mouth. If the provider determines the lesions to be impetigo contagiosa, what should the nurse anticipate illness? (Select all that apply.) A. Apply a topical antibacterial ointment to the lesions B. Wash the child's bed linens daily with hot water C. Administer acyclovir oral suspension to prevent recurrence D. Allow the crust covering the infected lesions to remain intact E. Wash hands before and after contact with the affected area

Correct Answer: C. 3 oz grilled chicken, 1 cup of pear slices, and 120 ml (4 oz) of apple juice ** A child who has glomerulonephritis has moderate sodium restriction, and further restriction is given to foods that are high in potassium for children who have decreased urinary output. These restrictions are because the kidneys of these children are not functioning appropriately. This menu option consists of 571 g of potassium and 268 g of sodium. Incorrect Answers: A. This lunch option consists of 921 gof potassium and 734 g of sodium. B. This lunch option consists of 1,119 g of potassium and 1,132 g of sodium. D. This lunch option consists of 655 g of potassium and 712 g of sodium.

A nurse is caring for a school-age child who has glomerulonephritis. The child has decreased urinary output and a blood pressure of 160/78 mmHg and receiving hydralazine. Which of the following lunch choices should the nurse recommend? A. 1 hot dog, 22 potato chips, and 120 mL (4 oz) of orange juice B. 1 sandwich with lettuce, tomato, and 4 slices of bacon; a small apple; and 240 mL (8 oz) of milk C. 3 oz grilled chicken, 1 cup of pear slices, and 120 mL (4 oz) of apple juice D. 1 cup of cottage cheese, a small banana, and 240 mL (8 oz) of soda

Correct Answer: D. Place the child on a pressure-reduction mattress ** Placing the child on a pressure-reduction mattress will alleviate the pressure on bony prominences, which decreases the risk of skin breakdown. Incorrect Answers: A. The nurse should not release or lift the weights that are applying the traction for any reason. If an issue should arise in which the weights require adjustment, the nurse should contact the provider or the physical therapist, depending on facility policy. B. The immobility associated with traction causes constipation. Therefore, the nurse should promote the intake of a high-fiber diet and ensure the child's meal tray contains as many high-fiber foods as the child will consume. C. The body should be maintained in correct alignment, and the joints should be kept at the angles set by the provider and the physical therapist, depending on the child's injuries. Performing passive range-of-motion exercises on the child's involved joints could cause further injury to the extremities. However, active and passive range-of-motion exercises should be performed on uninvolved joints.

A nurse is caring for a school-age child who has skeletal traction applied to repair a pelvic fracture. Which of the following actions should the nurse take? A. Rest the child's traction weights on the floor for 8 hr during the night B. Ensure the child's meal tray contains no high-fiber foods C. Perform passive range-of-motion exercises on the child's involved joints every 4 hr D. Place the child on a pressure-reduction mattress

Correct Answer: B. Ease the child to the floor in Sims' position ** The greatest risk to the child is an injury resulting from a fall; therefore, the nurse should first gently ease the child to the floor to decrease the chance of injury and turn the child on the left side to prevent aspiration. Incorrect Answers: A. The nurse should obtain portable suction machine and suction tubing; however, there is another action the nurse should take first. C. The nurse should time the length of the seizure. If the seizure duration is 5 minutes or greater, the nurse should administer a benzodiazepine medication for status epilepticus; however, there is another action the nurse should take first. D. The nurse should notify the child's parents after the child is stable following the seizure episode; there is another action the nurse should take first.

A nurse is caring for a school-aged child who begins to have a tonic-clonic seizure when leaving the bathroom. Which of the following actions should the nurse take first? A. Obtain a portable suction machine and suction tubing B. Ease the child to the floor in Sims' position C. Time the length of the seizure D. Notify the child's parents

Correct Answer: C. The child reports tightness at the wrist ** The nurse should monitor the casted extremity to ensure the swelling does not increase and cause the cast to become too tight, which can result in impaired circulation. If this occurs, the child is at risk for compartment syndrome. Incorrect Answers: A. The nurse should expect the child to have mild to moderate pain due to the fracture; therefore, a pain level of 5 on a scale of 0 to 10 is an expected finding. If the pain becomes severe and is unrelieved by analgesics, it could indicate an impairment in circulation. B. The nurse should monitor the child for indications of impaired circulation after a cast is applied. The nurse should be concerned if only the casted extremity is cool but not if the finding is bilateral. D. The nurse should expect the child to have impaired function such as a weak grasp due to the fracture. However, if the child develops paralysis of the extremity, it could indicate an impairment in circulation.

A nurse is caring for a school-aged child who had an arm cast applied 8 hours ago. Which of the following findings should alert the nurse to a complication related to the casting? A. The child reports a pain level of 5 on a scale of 0 to 10 B. The child's hands are cool bilaterally C. The child reports tightness at the wrist D. The child's grasp is weak

Correct Answer: D. Apply an ice pack to the joint ** Immediately following an injury, a joint should be rested, elevated, and have ice applied to minimize bleeding into the joint. Incorrect Answers: A. The nurse should avoid giving clients with hemophilia aspirin or NSAIDS because these medications can interfere with the action of platelets. B. Passive range-of-motion exercises should never be performed on a client with hemophilia. Over-stretching and tearing could inadvertently occur, resulting in further joint bleeding. C. Cryoprecipitate is no longer used to treat clients with hemophilia due to the inability to remove hepatitis and HIV completely from the product. Hemophilia is currently treated with factor VIII replacement products or a synthetic form of vasopressin.

A nurse is caring for a school-aged child who has hemophilia and fell on the playground. The child reports a pain level of 4 on a scale of 0 to 10. Which of following actions should the nurse take? A. Administer an NSAID B. Perform passive range-of-motion exercises on the joint C. Administer cryoprecipitate D. Apply an ice pack to the joint

Correct Answer: A. Slurred speech ** The nurse should identify that slurred speech in a child who has sickle cell anemia is an indication of a stroke. The nurse should report this finding to the provider immediately. Incorrect Answers: B. The nurse should identify that a hemoglobin level of 9 g/dL is below the expected reference range of 10 to 15.5 g/dL and is an expected finding for a child who has sickle cell anemia. This finding does not need to be reported to the provider. C. The nurse should identify that hematuria is an expected finding of a vaso-occlusive crisis and does not need to be reported to the provider. D. The nurse should identify that pain is an expected finding of a vaso-occlusive crisis and should implement interventions to promote the child's level of comfort. This finding does not need to be reported to the provider.

A nurse is caring for a school-aged child who has sickle cell anemia and was admitted for a vaso-occlusive crisis. Which of the following findings should the nurse report to the provider immediately? A. Slurred speech B. Hemoglobin level of 9 g/dL C. Hematuria D. Pain level of 7 on FACES scale

Correct Answer: A. Provide adequate fluid intake throughout the day ** Adequate hydration is an effective strategy to help prevent sickle cell crises. Maintaining adequate hydration can reduce the risk of sickle cell formation. Incorrect Answers: B. Oxygen might be necessary to manage a sickle cell crisis, but it is not routinely used to prevent a crisis. C. A blood transfusion might be necessary to manage a sickle cell crisis, but it is not routinely used to prevent a crisis. D. The nurse can administer ibuprofen to manage the pain of a sickle cell crisis, but this measure will not prevent a crisis from occurring.

A nurse is caring for a school-aged child who has sickle cell anemia. Which of the following actions should the nurse plan to take to help decrease the risk of a vaso-occlusive crisis? A. Provide adequate fluid intake throughout the day B. Provide oxygen at 2 L/min via nasal cannula C. Administer a blood transfusion D. Give ibuprofen to manage pain

Correct Answer: A. Position the child on his side ** Using evidence-based practice, the nurse should first position the child on his side. Salivation increases and the swallowing reflex is lost during a tonic-clonic seizure, placing the child at risk for aspiration. It is essential to maintain the airway during a seizure. Incorrect Answers: B. The nurse should measure the child's vital signs during the postictal period, which occurs just after the seizure has ended; however, evidence-based practice indicates that the nurse should take a different action first. C. The nurse should loosen restrictive clothing to reduce the possibility of further injury during the seizure; however, evidence-based practice indicates that the nurse should take a different action first. D. The nurse should check the child for head injuries during the postictal period; however, evidence-based practice indicates that the nurse should take a different action first.

A nurse is caring for a school-aged child who is having a tonic-clonic seizure. Which of the following actions should the nurse perform first? A. Position the child on his side B. Measure the child's vital signs C. Loosen any restrictive clothing D. Check the child for head injuries

Correct Answer: 25

A nurse is caring for a toddler and is preparing to administer 0.9% sodium chloride 100 mL IV infused over 4 hr. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number and use a leading zero if applicable. Do not use a trailing zero.)

Correct Answer: D. Pad the rails of the toddler's bed ** When caring for a toddler who has manifestations of bacterial meningitis, the nurse should implement seizure precautions, which includes padding the side rails of the bed. Incorrect Answers: A. When caring for a toddler who has a fever, the nurse should administer acetaminophen rather than aspirin because aspirin is associated with the development of Reye syndrome. B. When caring for a toddler who has a fever, the nurse should avoid giving the toddler a cold bath because it can cause shivering and discomfort. C. When caring for a toddler who has manifestations of bacterial meningitis, the nurse should keep the head of the bed slightly elevated to decrease intracranial pressure.

A nurse is caring for a toddler who has a fever, a high-pitched cry, irritability, and vomiting. Which of the following actions should the nurse take? A. Administer 81 mg of aspirin to the toddler B. Give the toddler a cold bath C. Place the toddler in a supine position D. Pad the rails of the toddler's bed

Correct Answer: C. Encourage rooming-in ** Rooming-in is the most effective means of providing emotional support for a toddler. The family's presence provides a sense of security that increases the child's ability to cope with an unfamiliar environment. Incorrect Answers: A. Toddlers are not as concerned about privacy as school-age children and adolescents. These children prefer to be with someone during procedures. B. A nurse should provide short, simple explanations for a toddler. A long explanation might cause the child's anxiety to increase. D. When speaking to a toddler, the nurse should refrain from using the word "fix" because the toddler may assume she is broken. Instead, the nurse should say, "I will help make you feel better."

A nurse is caring for a toddler who has asthma. The parents are concerned about the toddler's reaction to the hospitalization. Which of the following actions should the nurse take to decrease the child's anxiety? A. Provide privacy B. Give the child a thorough explanation before providing care C. Encourage rooming-in D. Tell the child you will help fix her

Correct Answer: B. Initiate contact precautions ** Salmonella is a type of bacteria that is transmitted via contaminated feces, making contact precautions essential for preventing transmission. This client is at greatest risk for transmission of Salmonella to others; therefore, contact precautions are the nurse's priority. Incorrect Answers: A. Throughout the course of gastroenteritis, the nurse should monitor the child's weight so essential nutrition support can be provided. The nurse should weigh the child to evaluate the degree of weight loss; however, another action is the nurse's priority. C. Throughout the course of gastroenteritis, the child's skin must be protected. The nurse should establish a skin care routine for the child; however, another action is the nurse's priority. D. The nurse should obtain a recent food history to determine how the child acquired the infection and the source of the Salmonella transmission; however, another action is the priority.

A nurse is caring for a toddler who has gastroenteritis caused by Salmonella. Which of the following is the priority action for the nurse? A. Weigh the child B. Initiate contact precautions C. Establish a skin care routine D. Obtain a recent food history

Correct Answer: D. Administer an antipyretic to the child ** When using the urgent vs. nonurgent approach to client care, the nurse should first administer an antipyretic to decrease the toddler's body temperature. Incorrect Answers: A. Reducing the room temperature is an effective method of reducing the toddler's temperature when implemented about 1 hour after the administration of an antipyretic. Therefore, this is not the first action the nurse should take. B. Redressing the child in minimal clothing is an effective method of reducing the toddler's temperature when implemented about 1 hour following the administration of an antipyretic. Therefore, this is not the first action the nurse should take. C. Applying cool compresses to the toddler's forehead is an effective method of reducing the toddler's temperature when implemented about 1 hour after the administration of an antipyretic. Therefore, this is not the first action the nurse should take.

A nurse is caring for a toddler who has otitis media and a temperature of 39.1°C (102.4°F). Which of the following actions should the nurse take first? A. Reduce the temperature of the child's room B. Redress the child in minimal clothing C. Apply cool compresses to the child's forehead D. Administer an antipyretic to the child

Correct Answer: A. Restrain the toddler's arms at the elbows ** When caring for a toddler who is postoperative following a cleft palate repair, the nurse should apply elbow restraints (unless prescribed otherwise) to prevent the toddler from rubbing or disrupting the sutured area. Incorrect Answers: B. When caring for a toddler who is postoperative following a cleft palate repair, the nurse should avoid the use of hard utensils due to the risk of injury to the repair. C. When caring for a toddler who is postoperative following a cleft palate repair, the nurse should avoid placing rigid objects in the mouth such as a thermometer due to the risk of injury to the repair. D. When caring for a toddler who is postoperative following a cleft palate repair, the nurse should weigh the infant at the same time of each day using the same scale in order to check nutritional status.

A nurse is caring for a toddler who is postoperative following a cleft palate repair. Which of the following actions should the nurse take? A. Restrain the toddler's arms at the elbows B. Feed the toddler with a spoon C. Monitor the toddler's oral temperature D. Weigh the toddler every 48 hours

Correct Answer: C. Creatinine 0.9 mg/dL ** The expected reference range for a toddler is a creatinine level of 0.3 to 0.7 mg/dL. This child's level is above the expected reference range and should be reported to the provider. Incorrect Answers: A. The expected reference range for a toddler is BUN 5 to 18 mg/dL. B. The expected reference range for a toddler is a uric acid level of 2.0 to 5.5 mg/dL. D. The expected reference range for a toddler is a urine specific gravity of 1.001 to 1.030.

A nurse is caring for a toddler. Which of the following laboratory findings should the nurse report to the provider? A. BUN 8 mg/dL B. Uric acid 3.0 mg/dL c. Creatinine 0.9 mg/dL D. Urine specific gravity 1.010

Correct Answer: D. 10-piece wooden puzzle ** Age-appropriate toys for a toddler include puzzles, large crayons, blocks, picture books, push-pull toys, finger paints, modeling clay, and musical toys. These toys all allow manipulation and exploration and meet the child's developmental and diversional activity needs. Incorrect Answers: A. Some dolls have accessories that are small and could present a choking hazard for the child. This selection is better for a preschooler or a school-age child. B. Most toddlers are not ready to read and learn the alphabet. This selection is better for a preschooler. C. Video games do not address a toddler's developmental and diversional activity needs. This selection is better for a preschooler or school- age child.

A nurse is caring for a toddler. Which of the following objects should the nurse select from the playroom for this child during hospitalization? A. Small plastic doll with clothes and accessories B. Alphabet flash cards C. Handheld video game D. 10-piece wooden puzzle

Correct Answer: C. Speech patterns ** Chronic otitis media can result in hearing loss, which can affect speech development. Incorrect Answers: A. Complications of otitis media include meningitis, labyrinthitis, and various types of abscesses and thromboses. However, the condition does not generally affect olfaction. B. Complications of otitis media do not generally affect visual acuity. D. Complications of otitis media do not generally affect hand-eye coordination.

A nurse is caring for an 18-month-old infant who has chronic otitis media. The nurse should recognize that chronic otitis media will affect which of the following? A. Olfaction B. Visual acuity c. Speech patterns D. Hand-eye coordination

Correct Answer: B. Meningococcal polysaccharide The meningococcal polysaccharide immunization is used to prevent infection by certain groups of meningococcal bacteria. Meningococcal infection can cause life-threatening illnesses, such as meningococcal meningitis (which affects the brain) and meningococcemia (which affects the blood). Both of these conditions can be fatal. College freshmen, particularly those who live in dormitories, are at an increased risk for meningococcal disease relative to other persons their age. Therefore, the Centers for Disease Control and Prevention issued a recommendation that all incoming college students receive the meningococcal immunization. Incorrect Answers: A. The pneumococcal polysaccharide immunization is administered to children between the ages of 2 and 18 years who have a specific high- risk condition that places them at risk for an infection with Streptococcus pneumococci, a bacterium that causes meningitis, otitis media, and pneumonia. C. The final dose of the rotavirus immunization is administered prior to the age of 8 months. An additional booster dose is notrecommended. D. The herpes zoster immunization is recommended for adults over the age of 60 to prevent an episode of shingles.

A nurse is caring for an 18-year-old adolescent who is up-to-date on immunizations and is planning to attend college. The nurse should recommend which of the following immunizations prior to moving into a campus dormitory? A. Pneumococcal polysaccharide B. Meningococcal polysaccharide C. Rotavirus D. Herpes zoster

Correct Answer: D. Periorbital edema ** Periorbital edema is an expected finding in a child who has glomerulonephritis. Incorrect Answers: A. Elevated blood pressure is an expected finding in a child who has acute glomerulonephritis. B. Stomatitis is an expected finding in a child who has chronic renal failure. C. Bloody diarrhea is an expected finding in a child who has hemolytic uremic syndrome.

A nurse is caring for an 8-year-old child who has acute glomerulonephritis. Which of the following findings should the nurse expect? A. Hypotension B. Stomatitis C. Bloody diarrhea D. Periorbital edema

Correct Answer: C. Give the child flavored popsicles ** Maintaining hydration with a child who has sickle cell anemia is important to prevent sickling. Children often accept flavored popsicles a source of fluid. Incorrect Answers: A. Cool compresses cause vasoconstriction and might prompt further occlusions. B. A child who has an infection transmitted by direct contact (e.g. Clostridium difficile) requires contact precautions. D. A client who has a warfarin overdose should receive phytonadione. A child who has sickle cell anemia should not receive a warfarin antidote.

A nurse is caring for an 8-year-old child who has sickle cell anemia. Which of the following actions should the nurse take? A. Apply cool compresses to the painful area B. Initiate contact isolation precautions C. Give the child flavored popsicles D. Administer phytonadione

Correct Answer: D. Pruritus ** Pruritus is an adverse effect of opioids. Constipation, respiratory depression, nausea, vomiting, agitation, orthostatic hypotension, and hallucinations are also adverse effects of opioids. Incorrect Answers: A. Dilated pupils a emanifestations of withdrawal from opioids. B. Tremors are manifestations of withdrawal from opioids. C. Yawning is a manifestation of withdrawal from opioids.

A nurse is caring for an adolescent client who has a prescription for opioids. Which of the following findings should the nurse recognize as an adverse effect of opioids? A. Dilated pupils B. Tremors C. Yawning D. Pruritus Answer

Correct Answer: B. Place the adolescent in a supine position ** The nurse should place the adolescent in a supine position for 30 minutes to 1 hour following a lumbar puncture to decrease the risk of a post-dural puncture headache. Incorrect Answers: A. The nurse should encourage the adolescent to consume fluids following a lumbar puncture to promote replacement of cerebrospinal fluid, C. The nurse should assist the provider in applying an adhesive bandage to the puncture site following the procedure. The nurse should avoid the application of heat because it promotes blood flow to the site, which increases the client's risk for bleeding. D. The nurse should apply EMLA cream to the puncture site at least 1 hour prior to the lumbar puncture to decrease the adolescent's pain during the procedure.

A nurse is caring for an adolescent following a lumbar puncture. Which of the following actions should the nurse take? A. Initiate NPO status for the adolescent B. Place the adolescent in a supine position C. Place a moist, warm pack on the adolescent's lower back D. Apply a eutectic mixture of local anesthetics (EMLA) to the adolescent's puncture site

Correct Answer: C. Obtain the adolescent's weight prior to the procedure ** The nurse should obtain a baseline weight prior to the initiation of the procedure and again following the procedure. Incorrect Answers: A. The nurse should elevate the head of the adolescent's bed to minimize upward pressure on the diaphragm from the dialysate. B. The nurse should have the adolescent empty his bladder prior to the procedure to allow maximum space in the anterior peritoneal cavity. The adolescent does not need to drink fluids prior to the procedure. D. The nurse should monitor the adolescent's vital signs at least every hour during the procedure.

A nurse is caring for an adolescent who has end-stage renal disease and is scheduled for peritoneal dialysis. Which of the following actions should the nurse take? A. Position the adolescent supine during the procedure B. Have the adolescent drink 240 mL (8 oz) of fluid prior to the procedure C. Obtain the adolescent's weight prior to the procedure D. Monitor the adolescent's vital signs every 4 hours during the procedure

Correct Answers: A. Enlarged heart B. Enuresis C. Leg ulcers E. Retinal detachment ** Chronic vaso-occlusive phenomena result from the obstruction of organs by red blood cells, leading to stasis and enlargement of the organs, infarction due to ischemia, and scarring. An enlarged heart, enuresis, leg ulcers, and retinal detachment are manifestations of chronic vaso- occlusive phenomena. Incorrect Answer: D. Intrahepatic cholestasis is a manifestation of chronic vaso-occlusive phenomena. Extrahepatic cholestasis is caused by the blockage of

A nurse is caring for an adolescent who has sickle cell anemia. Which of the following manifestations is/are the result of chronic vaso-occlusive phenomena? (Select all that apply.) A. Enlarged heart B. Enuresis C. Leg ulcers D. Extrahepatic cholestasis E. Retinal detachment

Correct Answer: D. Reinforce teaching with the client about how to push the button to deliver the medication ** The appropriate action at this time is to reinforce client teaching about the PCA. The nurse should remind the client about the availability of the medication, verify that the client knows how to use the equipment, and emphasize the importance of using it regularly to manage pain effectively. Incorrect Answers: A. A PCA device allows the adolescent to be in charge of pain management and is an effective method of controlling pain. It is inappropriate for the nurse to suggest discontinuing the PCA. B. One of the principles of PCA is that no one other than the client or the nurse pushes the button to deliver the medication. An adolescent is capable of maintaining effective pain control using a PCA. C. Moderate (5 to 6) or severe pain (7 to 10) requires the use of opioids for effective pain management. A PCA delivers an appropriate amount of opioid to treat moderate pain, and the client should be encouraged to push the PCA button to deliver the medication at this time.

A nurse is caring for an adolescent who is receiving pain medication via a PCA pump. When the nurse assesses the client's pain at 0800, the client describes the pain as a 3 on a scale of 1 to 10. At 1000, the client describes the pain as a 5. The nurse discovers the client has not pushed the button to deliver medication in the past 2 hr. Which of the following actions should the nurse take? A. Ask the provider to discontinue the PCA so the nurse can administer PRN pain medication B. Suggest the client's parent push the button for the client if the parent thinks the adolescent is having pain C. Reevaluate the client in 1 hr since a pain level of 5 is acceptable on a scale of 1 to 10 D. Reinforce teaching with the client about how to push the button to deliver the medication

Correct Answer: B. Suction the infant gently with a bulb syringe PRN ** The nurse should gently suction the infant's mouth with a bulb syringe to maintain a patent airway. Incorrect Answers: A. The nurse should avoid placing objects in the infant's mouth during the postoperative period to avoid trauma to the incision. C. The nurse should position the infant upright to facilitate the drainage of secretions. Placing the infant in a prone position could lead to aspiration. D. The nurse should clean the operative incision with sterile saline or sterile water after each feeding and as needed.

A nurse is caring for an infant following the surgical repair of a cleft lip and palate. Which of the following actions should the nurse take? A. Keep the infant's mouth open by using a tongue blade for 4 hr following surgery B. Suction the infant gently with a bulb syringe PRN C. Place the infant in a prone position D. Clean the infant's incision with chlorhexidine

Correct Answer: D. Difficulty with language acquisition ** Clients who have a cleft palate can have difficulty acquiring language because they need to use the palate for vocalizing sounds. Because of the cleft in the palate, these infants could develop poor speech habits. Incorrect Answers: A. Infants who have a cleft palate are at increased risk of ear infections; however, this can persist even after the repair of the palate. B. Infants who have a cleft palate are at increased risk for poor nutrition due to feeding difficulties. However, there are multiple strategies to teach the parents to promote nutrition and to help the infant create a seal and generate suction to feed. C. Repair of a cleft palate does not affect the child's immune system. However, repairing the palate too soon can affect the skeletal growth of the mid portion of the child's face.

A nurse is caring for an infant who has a cleft palate. The parents ask the nurse how long they should wait before the child can have corrective surgery. The nurse should explain that the parents should wait no longer than 6 to 12 months for surgery to prevent which of the following outcomes? A. Repeated ear infections B. Nutritional deficits C. Immune system deficits D. Difficulty with language acquisition

Correct Answer: B. Perform oropharyngeal suctioning ** When caring for an infant who has a tracheoesophageal fistula, the nurse should perform frequent oropharyngeal suctioning to decrease infant's risk of aspiration. Incorrect Answers: A. When caring for an infant who has a tracheoesophageal fistula, the nurse should position the infant supine on an inclined plane with the head elevated to decrease the risk of aspiration. C. When caring for an infant who has a tracheoesophageal fistula, the nurse should maintain the infant on NPO status due to the risk of aspiration. D. When caring for an infant who has a tracheoesophageal fistula, the nurse should maintain the infant on NPO status due to the risk of aspiration.

A nurse is caring for an infant who has a tracheoesophageal fistula. Which of the following actions should the nurse take? A. Place the infant in a lateral position B. Perform oropharyngeal suctioning C. Administer ranitidine orally D. Thicken the infant's formula

Correct Answers: A. Yellow sclerae D. Abdominal distention E. Dark urine ** Biliary atresia is a progressive process that leads to the destruction of the biliary tree. Yellow sclerae are an early manifestation of biliary atresia caused by obstruction of the biliary tree, resulting in cholestasis. Abdominal distention is a clinical manifestation of biliary atresia due to hepatomegaly. Dark urine is a clinical manifestation of biliary atresia due to conjugated bilirubin escaping from the liver and being excreted in the urine. Incorrect answers: B. Infants who have biliary atresia have difficulty metabolizing fat, leading to poor weight gain. C. Acholic or gray stools are a clinical manifestation of biliary atresia. Pale, putty-colored stools are due to the lack of bilirubin in the intestinal tract.

A nurse is caring for an infant who has biliary atresia. Which of the following manifestations should the nurse expect? (Select all that apply.) A. Yellow sclerae B. Rapid weight gain C. Tar-colored stools D. Abdominal distention E. Dark urine

Correct Answer: C. Longer intestinal tract ** Compared to adults or older children, infants have a longer intestinal tract. This results in greater fluid losses, especially through diarrhea. Incorrect Answers: A. Compared to adults or older children, infants have a larger amount of extracellular fluid. This results in a larger fluid volume and more rapid water loss in this age group. B. Compared to adults or older children, infants have a larger body surface area. This results in greater fluid losses through insensible means. D. Compared to adults or older children, infants have an increased rate of metabolism. This results in the production of more metabolic waste, which must be excreted by the kidneys.

A nurse is caring for an infant who has gastroenteritis and is dehydrated. Which of the following characteristics places the infant at a higher risk of electrolyte imbalances compared to an adult client? A. Less extracellular fluid B. Reduced body surface area C. Longer intestinal tract D. Decreased rate of metabolism

Correct Answer: D. Maintain a cardiorespiratory monitor ** Infants with pertussis typically present with apnea in response to coughing spasms and mucus plugs. Humidified oxygen and suction equipment should be used as needed. Incorrect Answers: A. Pertussis causes paroxysms of coughing with frequent vomiting. Therefore, infants who have pertussis are at risk of fluid volume deficit. B. The nurse should take this action when caring for a child who has a mumps infection, which causes enlarged, painful parotid glands. C. The nurse should initiate standard and droplet precautions when providing care for a client who has pertussis.

A nurse is caring for an infant who has pertussis. Which of the following actions should the nurse take? A. Assess for edema of the extremities B. Apply warm compresses to the neck area C. Initiate airborne precautions D. Maintain a cardiorespiratory monitor

Correct Answer: A. Place the infant in a knee-chest position ** The nurse should place the infant in a knee-chest position during a hypercyanotic episode. This position reduces the return of desaturated blood from the legs through the venous system and promotes the diversion of blood into the pulmonary artery. Incorrect Answers: B. The nurse should provide IV fluids as needed to treat the hypercyanotic episode. C. The nurse should apply a face mask to the infant and deliver 100% oxygen to treat the hypercyanotic episode. D. The nurse should expect to administer morphine to treat the hypercyanotic episode.

A nurse is caring for an infant who has tetralogy of Fallot and is experiencing a hypercyanotic episode. Which of the following actions should the nurse take? A. Place the infant in a knee-chest position B. Initiate a fluid restriction C. Provide oxygen by nasal cannula D. Administer acetaminophen

Correct Answer: C. Administer an antifungal medication after feedings ** The nurse should administer an antifungal medication to the infant after feedings to ensure adequate contact time with the oral mucosa and tongue to enhance treatment of the oral candidiasis. Incorrect Answers: A. The nurse should rinse the infant's mouth with water after feedings and prior to the application of antifungal medication. B. The nurse should identify that oral candidiasis is an adverse effect of antibiotic therapy. The nurse should implement measures to treat the candidiasis rather than discontinue treatment for the respiratory infection. D. The nurse should identify the need to treat both the infant and the mother for candidiasis simultaneously rather than discontinuing breastfeeding.

A nurse is caring for an infant who is breastfed and is receiving amoxicillin for an upper respiratory infection. An assessment of the mouth reveals whitish patches on the tongue that will not scrape off. Which of the following actions should the nurse take? A. Offer the infant water before feedings B. Discontinue amoxicillin C. Administer an antifungal medication after feedings D. Give the infant formula instead of breast milk

Correct Answer: A. Measure the client's weight daily ** When applying the urgent versus nonurgent priority-setting framework, the nurse should consider urgent findings the priority because they more readily indicate the degree of threat to the client. The nurse may also need to use nursing knowledge to identify which finding most critical. Daily weight measurements are the most sensitive indicator of fluid balance in clients of all ages. Daily weight measurements are especially critical for infants and children because fluid accounts for a greater portion of body weight. Incorrect Answers: B. Checking for the absence of tears is part of a hydration assessment. However, the lack of tears does not give the nurse precise information about the degree or severity of the infant's dehydration. Therefore, there is another assessment that is the priority. C. Palpating the fontanel is part of a hydration assessment. However, unless the fontanel is extremely sunken, this assessment does not give the nurse precise information about the degree or severity of the infant's dehydration. Therefore, there is another assessment that is the priority.

A nurse is caring for an infant who is experiencing dehydration. Which of the following assessments is the nurse's priority? A. Measure the client's weight daily B. Check for tears C. Palpate the fontanel D. Assess skin turgor

Correct Answer: B. Measure the infant's head circumference ** Increased head circumference is an indication that the infant is at greater risk of increased intracranial pressure; therefore, measuring the infant's head circumference is the priority nursing action. Hydrocephalus can occur as a complication of a myelomeningocele repair and is monitored using head circumference measurements. Incorrect Answers: A. Measuring the infant's intake and output is an essential component of postoperative care. However, the greatest risk to this infant is neurological complications. Therefore, this action is not the nurse's priority. C. Checking the infant's lower-extremity function is an essential component of postoperative care. However, the greatest risk to this infant is neurological complications. Therefore, this action is not the nurse's priority. D. Monitoring the infant's blood pressure is an essential component of postoperative care. However, the greatest risk to this client is neurological complications. Therefore, this action is not the nurse's priority.

A nurse is caring for an infant who is postoperative following a myelomeningocele repair. Which of the following is the priority action the nurse should take? A. Measure the infant's intake and output B. Measure the infant's head circumference C. Check the infant's lower-extremity function D. Monitor the infant's blood pressure

Correct Answer: C. Prone ** When providing preoperative care for an infant who has a myelomeningocele, the nurse should maintain the infant in a prone position. This position reduces pressure and the risk of trauma to the sac. Incorrect Answers: A. When providing preoperative care for an infant who has a myelomeningocele, the nurse should avoid placing the infant in a side-lying position. This position places direct pressure on the sac and increases the infant's risk of trauma. B. When providing preoperative care for an infant who has a myelomeningocele, the nurse should avoid placing the infant in a supine position. This position places direct pressure on the sac and increases the infant's risk of trauma. D. When providing preoperative care for an infant who has a myelomeningocele, the nurse should avoid placing the infant in a semi-Fowler's position. This position places direct pressure on the sac and increases the infant's risk of trauma.

A nurse is caring for an infant who is preoperative for the treatment of an intact myelomeningocele sac. In which of the following positions should the nurse place the infant? A. Side-lying B. Supine C. Prone D. Semi-Fowler's

Correct Answers: B. Ability to build a tower of 6 blocks D. Slightly bowed or curved leg appearance ** The nurse should expect a 24-month-old toddler to be able to stack a short tower of 6 or 7 blocks. Additionally, a 24-month-old toddler will have a "pot-bellied" appearance; the legs should be slightly bowed to support the weight of the comparatively large trunk. Incorrect Answers: A. The nurse should expect a 24-month-old toddler to have 16 teeth. C. The nurse should expect a 24-month-old toddler to have a vocabulary of about 300 words and to be able to speak in 2- to 3-word phrases. E. The nurse should expect a 24-month-old toddler to have a head circumference that is equal to or less than the chest circumference.

A nurse is conducting a health assessment for a 24-month-old toddler at the local health department. The nurse should expect which of the following findings? (Select all that apply.) A. 8 deciduous teeth B. Ability to build a tower of 6 blocks C. Vocabulary of 10-20 words D. Slightly bowed or curved leg appearance E. Head circumference greater than chest circumference

Correct Answer: D. Cover the oximetry sensor with clothing ** The nurse should cover the sensor with clothing to prevent outside light from causing an altered or false reading. Incorrect Answers: A. The nurse should move the sensor to a new site every 4 to 8 hours. The pulse oximetry sensor should not remain in a single location for an extended period of time because of the risk of tissue necrosis. B. The pulse oximetry sensor should be placed around the infant's hand or foot to obtain an accurate reading. C. The pulse oximeter uses a sensor to measure oxygen in the infant's hemoglobin. Conduction gel would interfere with the reading because it would not allow the sensor to attach to the skin.

A nurse is creating a plan of care for a 6-month-old infant who requires continuous pulse oximetry monitoring. Which of the following interventions should the nurse include? A. Reposition the sensor to a new site once every 24 hr B. Secure the oximetry sensor to the infant's wrist C. Apply conduction gel to the skin before attaching the sensor D. Cover the oximetry sensor with clothing

Correct Answer: A. Initiate protective-environment isolation for the child ** The nurse should suggest protective-environment isolation for the child, which consists of a private room with positive air pressure and no live flowers; nurses must don a respirator mask, gloves, and gown prior to entering the child's room. A child who has aplastic anemia has decreased RBCS, platelets, and WBCS, causing immune suppression and increasing susceptibility to infection. Incorrect Answers: B. Aplastic anemia decreases the production of RBCS, WBCS, and platelets, which increases the child's risk for bleeding. The nurse should apply pressure to peripheral puncture sites for a minimum of 5 minutes to prevent bleeding following blood specimen collection. C. Ferrous sulfate is a required medication for a child who has iron-deficiency anemia, so it is not a necessary intervention for this client. The nurse should avoid mixing medications into liquids because if the child fails to drink the entire glass, the dosage received is not complete. D. Aplastic anemia does not affect the child's blood glucose level, so this is not a necessary intervention.

A nurse is creating a plan of care for a child who has aplastic anemia. Which of the following interventions should the nurse include? A. Initiate protective-environment isolation for the child B. Apply pressure for 1-2 min at the puncture site following blood specimen collection C. Mix the child's ferrous sulfate elixir twice per day into a glass of milk for administration D. Check the child's blood glucose level every 4 hr

Correct Answer: B. Monitor the child for increased temperature ** Leukopenia places the child at risk of infection; therefore, the nurse should monitor the child for a fever. Incorrect Answers: A. The nurse should maintain bed rest for the child who has decreased RBCS. C. The nurse should administer oxygen to a child who has decreased RBCS and low oxygen saturation. D. The nurse should monitor a child who has a low platelet level for bleeding.

A nurse is creating a plan of care for a child who has leukopenia secondary to chemotherapy. Which of the following interventions should the nurse include in the plan? A. Maintain the child on bed rest B. Monitor the child for increased temperature C. Administer oxygen to the child D. Monitor the child for bleeding

Correct Answer: A. Monitor the child's oxygen saturation level ** When using the airway, breathing, and circulation (ABC) approach to client care, the priority intervention is to monitor the child's oxygen saturation level. Promoting oxygen utilization prevents further sickling of the child's red blood cells and allows adequate oxygenation of the surrounding tissue. Incorrect Answers: B. The nurse should administer prescribed antibiotics to treat any existing infection. However, another intervention is the priority to include in the plan of care. C. The nurse should encourage fluid intake to prevent dehydration and clumping of red blood cells. However, another intervention is the priority to include in the plan of care. D. The nurse should apply a warm compress to the joints to reduce pain and inflammation. However, another intervention is the priority to

A nurse is creating a plan of care for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions is the priority for the nurse to include? A. Monitor the child's oxygen saturation level B. Administer prescribed antibiotics to the child C. Increase the child's fluid intake D. Apply warm compresses to the child's affected joints

Correct Answer: D. Putting together a puzzle with large pieces ** The nurse should recommend putting together a puzzle with large pieces for a hospitalized preschooler. Other recommended activities for preschoolers on airborne precautions include playing pretend and dress up, painting, and looking at illustrated books. Incorrect Answers: A. Constructing a model airplane is advanced for a preschooler's fine motor skills. However, preschoolers do not have the skills or the attention span to build models. This activity is appropriate for a school-age child. B. A preschooler who has the measles is on airborne precautions and should not be in the playroom, as this would expose other children to the disease. The particles can be dispersed widely throughout the air and could be inhaled by another child in the playroom. C. A preschooler who has the measles is on airborne precautions and should not be outside of the hospital room. Pulling a wagon in the hallway would likely spread this disease by dispersing particles containing infectious agents to other children who are either in the hallway

A nurse is creating a plan of care for a preschooler who was admitted for the treatment of measles. Which of the following activities should the nurse include in the client's care plan? A. Constructing a model airplane B. Playing a video game in the playroom C. Pulling a wagon with toys in the hallway D. Putting together a puzzle with large pieces

Correct Answer: C. Use manual jaw control when feeding the toddler ** The nurse should encourage the parent to include the use of manual jaw control during feedings. Children diagnosed with cerebral palsy can lose jaw control, and more effective control can be achieved by providing stability to the jaws during feeding. Incorrect Answers: A. Due to the risk of injury for both healthy children and children diagnosed with cerebral palsy, the use of mobile infant walkers is discouraged. B. The nurse should encourage activities involving repetitive joint movement for children diagnosed with cerebral palsy. These activities will assist with fine and gross motor development. D. Wrist splints can assist in maintaining or increasing the mobility of children diagnosed with cerebral palsy. Therefore, the nurse should encourage the use of these devices.

A nurse is creating a plan of care for an 18-month-old toddler who has cerebral palsy. Which of the following interventions should the nurse include? A. Use a mobile walker for the toddler B. Discourage activities involving repetitive joint movement C. Use manual jaw control when feeding the toddler D. Discourage the use of wrist splints

Correct Answer: A. Higher body fat content is associated with earlier onset of menarche ** The nurse should inform the parents that the onset of menarche is expected to occur around 10.5 to 15.5 years of age. Females who have a higher body fat content have been shown to have an earlier onset of menarche. Incorrect Answers: B. The nurse should inform the parents that breast development usually begins around 8 to 12 years of age, followed 2 to 6 months later the appearance of pubic hair. C. The nurse should inform the parents that ovulation is stimulated by the increasing amount of estrogen that develops after the onset of menarche. This increased level of estrogen promotes further sexual maturation. D. The nurse should inform the parents that menarche is an indication of late puberty. The onset of menstrual periods is preceded by an increase in height, breast development, and the appearance of pubic hair.

A nurse is developing a health education program for the parents of school-aged females. Which of the following pieces of information regarding sexual maturation should the nurse include? A. Higher body fat content is associated with earlier onset of menarche B. Pubic hair is typically present prior to breast development C. Ovulation begins after sexual maturation is complete D. Menarche signals the beginning of puberty

Correct Answer: B. Explain the sounds the child is hearing ** The noises in a facility can be frightening to a child who is experiencing a sensory loss. Explaining these noises can allay the child's fears. Incorrect Answers: A. Children who experience a loss of vision should be encouraged to participate in self-care activities, such as feeding, as much as possible. Items on the meal tray should be organized, and the child should be oriented to their location. Finger-foods should be offered. C. Children who have a temporary vision loss are not accustomed to using a cane. A child who has permanent vision loss can use a cane for ambulation and activities during hospitalization. D. Providing consistency in the child's environment promotes safety and security for the child. Interacting with the same nurse offers comfort and reassurance to the child and promotes increasing independence by building on the child's skills and abilities during hospitalization.

A nurse is developing a plan of care for a school-age child who underwent a surgical procedure that resulted in a temporary loss of vision. Which of the following interventions should the nurse include in the plan of care? A. Assign an assistive personnel to feed the child B. Explain the sounds the child is hearing C. Have the child use a cane when ambulating D. Rotate nurses caring for the child

Correct Answer: B. The guardian places the child in time-out after misbehaving ** The nurse should encourage the guardian to continue to use time-out as a form of discipline. This technique is effective with a preschooler if carried out correctly. The nurse should review the process of using time-outs with the guardian (e.g. ensuring the time-out takes place in a safe and quiet location) and recommend that the length of the time-out is 1 minute for each year of the child's age. Incorrect Answers: A. The nurse should inform the guardian that a preschooler is in the preoperative stage of cognitive development. Therefore, the child is not yet able to understand fully why an action is wrong. C. The nurse should inform the guardian that a preschooler is in the preoperative stage of cognitive development. Therefore, the child is not yet able to understand how consequences match misbehaviors. The nurse should recommend the guardian decide ahead of time what the consequence should be and then consistently follow through with that consequence if misbehavior occurs. D. The nurse should inform the guardian that assigning an extra chore for misbehavior is an example of an unrelated consequence and should provide the guardian with information about natural and logical consequences. A natural consequence occurs without intervention from the guardian (e.g. getting burned after touching a heater even though the child knows it is dangerous). A logical consequence is directly related to an established rule (e.g. not being allowed to have dessert until the child has eaten vegetables at dinner).

A nurse is discussing disciplinary techniques with the guardian of a preschooler. Which of the following actions indicates to the nurse that the guardian is using an age-appropriate disciplinary technique? A. The guardian explains to the child why her behavior is unacceptable B. The guardian places the child in time-out after misbehaving C. The guardian allows the child to choose the consequence of her misbehavior D. The guardian assigns an extra chore for the child's misbehavior

Correct Answer: B. Pushing a toy lawn mower ** The nurse should recommend pushing a toy lawn mower as a play activity for a toddler. Toddlers are developmentally ready for push-pull toys, and they enjoy play activities that allow imitation of adults. Incorrect Answers: A. Jumping rope is a play activity that meets the gross motor ability of a preschooler. C. The nurse should advise parents to avoid toys that pose a risk for aspiration by the toddler. D. Playing a board game is an activity that meets the developmental ability of a school-age child.

A nurse is discussing play activities with a group of parents of toddlers. Which of the following activities should the nurse recommend for this age group? A. Jumping rope B. Pushing a toy lawn mower C. Sorting colored marbles D. Playing a board game

Correct Answer: B. The color of the infant's stool is yellowish-brown ** An infant who has a biliary obstruction will have clay-colored stools because the flow of bilirubin into the intestinal tract is blocked. If the surgery is successful, the infant's stools will change to yellow and then brown in color. Incorrect Answers: A. Biliary obstruction prevents the absorption of fat due to the absence of bile salts in the intestinal tract, resulting in the excretion of fatty stools. Following the correction of the biliary obstruction, the infant's stools should appear less fatty. C. The direct bilirubin level should decrease if the surgery was successful because an indication of bile duct obstruction is an increase in direct bilirubin levels. D. Unrepaired biliary obstruction leads to hepatic cell destruction and cirrhosis. The presence of a firm liver can be noted upon palpation.

A nurse is evaluating the outcome of surgery for an infant who had a bile duct obstruction. Which of the following findings should indicate to the nurse that the surgery was successful? A. The infant's stool becomes fatty B. The color of the infant's stool is yellowish-brown C. The infant's direct bilirubin level has increased D. A palpable mass is noted in the infant's right upper quadrant

Correct Answer: B. Arm cast for a spiral fracture of the forearm ** Spiral fractures occur from the twisting of an extremity. In most instances, spiral fractures of the arm result from an abusive injury. Incorrect Answers: A. Bruising of the knees and sutures are typical findings associated with accidental childhood injuries, such as falling off a bicycle. Lacerations or abrasions to the backs of the legs are suggestive of physical abuse. C. Bedwetting has many causes and affects many preschoolers. In the absence of other findings, it does not indicate abuse. Pain with urination or recurrent urinary tract infections suggest sexual abuse. D. In the absence of other findings, these reports do not indicate abuse. However, abdominal pain and swelling accompanied by indications of punching are suggestive of physical abuse.

A nurse is facilitating a group discussion with preschool teachers about child abuse. Which of the following examples should the nurse use to illustrate a suggestive finding? A. Bruising of both knees with sutures on 1 B. Arm cast for a spiral fracture of the forearm c. Consistent bedwetting at nap time D. Frequent, vague reports of a stomachache or a headache

Correct Answer: B. Assign the child several small chores ** The nurse should recommend assigning the child several small chores. The completion of each chore in a short amount of time offers the child a sense of accomplishment and promotes the achievement of the developmental task of industry. Incorrect Answers: A. Providing consistent care that meets a physical need promotes trust; however, it doesn't promote industry. Trust is a developmental that should be achieved during infancy. C. Discussing career choices and plans for adulthood with an adolescent is a means of promoting the achievement of the developmental task of identity. D. Talking about the family's value system with an adolescent is a means of promoting the achievement of the developmental task of

A nurse is instructing a group of parents and guardians about child development. Which of the following recommendations should the nurse make to promote the developmental task of industry in the school-age child? A. Have an after-school snack ready for the child each day B. Assign the child several small chores C. Talk with the child about what future goals as an adult D. Talk openly about the family's value system

Correct Answer: C. Object permanence ** Object permanence refers to the cognitive skill of knowing an object still exists even when out of sight. By discovering a hidden object while playing peek-a-boo, the infant experiences validation of this concept. Incorrect Answers: A. Playing peek-a-boo does not further refine the infant's fine-motor skills unless the infant is using the hands to locate the hidden object. Hand-eye coordination is necessary for fine motor skills. B. Playing peek-a-boo does not establish a sense of trust. Trust is developed by consistent care given in the first year of life. D. Egocentrism refers to infant's self-centeredness and inability to see things from a point of view other than their own. An 8-month-old infant is considered egocentric.

A nurse is observing a mother who is playing peek-a-boo with her 8-month-old child. The mother asks if this game has any developmental significance. nurse should reply that peek-a-boo helps develop which of the following concepts in the child? A. Hand-eye coordination B. Sense of trust C. Object permanence D. Egocentrism

Correct Answer: B. Engaging in play near other children ** The nurse should identify that toddler play happens in parallel to that of other children. As socialization begins, the child plays alongside other children, not with them. Incorrect Answers: A. Play becomes associative at about 5 years of age when the child attempts to follow rules but might cheat to avoid losing. C. The nurse should not expect a 2-year-old child to understand the concept of sharing until around 3 years of age. D. The nurse should not expect a child to have the gross motor ability to skip and hop on 1 foot until about 4 years of age.

A nurse is observing the behavior of a 2-year-old child. Which of the following actions should the nurse expect to observe when the child is in an activity room with other toddlers? A. Playing a simple game with another child B. Engaging in play near other children C. Sharing crayons with another toddler D. Jumping on 1 foot without help

Correct Answer: C. Wash and dry the genitalia, perineum, and surrounding skin ** The first action the nurse should take is to wash and dry the genitalia, perineum, and the skin in the area to which the urine collection bag will be secured. Incorrect Answers: A. The nurse should apply the collection bag to the skin at the area of the symphysis pubis third, after applying the bag to the perineum. B. The nurse should apply the collection bag to the skin at the area of the perineum after washing and drying the genitalia, perineum, and surrounding skin. D. After applying the urine collection bag, the nurse can initiate the Perez reflex, which results in urination, by stroking the muscles on either side of the infant's spine. The Perez reflex is present in infants who are 4 to 6 months of age.

A nurse is obtaining a urine sample from a 5-month-old infant by applying a urine collection bag. Which of the following actions should the nurse take first? A. Apply the collection bag to the skin at the area of the symphysis pubis B. Apply the collection bag to the skin at the area of the perineum C. Wash and dry the genitalia, perineum, and surrounding skin D. Stroke the muscles on either side of the infant's spine

Correct Answer: A. Negative Babinski reflex ** The nurse should expect a negative Babinski reflex from a 15-month-old toddler because this reflex usually disappears around 12 months of age. Incorrect Answers: B. The nurse should expect a negative Moro reflex from a 15-month-old toddler because this reflex usually disappears around 4 months of age. C. The nurse should expect a positive corneal reflex (i.e. blink reflex) from a 15-month-old toddler because this is expected to be present at the time of birth. D. The nurse should expect the palmar grasp to be absent from a 15-month-old toddler because this reflex is usually replaced by the pincer grasp around 8 to 9 months of age.

A nurse is performing a neurological examination on a 15-month-old toddler. Which of the following findings should the nurse expect? A. Negative Babinski reflex B. Presence of the Moro reflex C. Absence of corneal reflexes D. Positive palmar grasp

Correct Answer: C. 18.2 ** To calculate the client's BMI, the nurse should divide the client's weight in kilograms by the square of the client's height in meters. Therefore, 41 kg divided by the square of 1.5 m gives a correct BMI of 18.2. Incorrect Answers: A. A value of 1.5 comes from dividing 90 lb by 60 inches, which is an incorrect calculation for BMI. B. A value of 3.6 comes from dividing 90 lb by the square of 5 feet, which is an incorrect calculation for BMI. D. A value of 27.3 comes from dividing 41 kg by 1.5 m, which is an incorrect calculation for BMI.

A nurse is performing a nutritional screening for a 12-year-old client who weighs 41 kg (90 Ib) and has a height of 1.5 m (60 in). Which of the following values is the client's body mass index (BMI)? A. 1.5 B. 3.6 C. 18.2 D. 27.3

Correct Answer: A. The infant's current weight is double his birth weight. ** The nurse should expect a 12-month-old infant's weight to be triple his birth weight; therefore, the nurse should report this finding to the provider. Incorrect Answers: B. The nurse should expect the infant's posterior fontanel to be closed at about 2 months of age. C. Although the ability to walk independently varies among infants, the nurse should not expect this gross motor skill until the infant is 13 to 15 months of age. D. The nurse should expect a 12-month-old infant to have 6 to 8 teeth present.

A nurse is performing a physical assessment on a 12-month-old infant. Which of the following findings should the nurse report to the provider? A. The infant's current weight is double his birth weight. B. The infant's posterior fontanel is closed. C. The infant is unable to walk without support. D. A total of 6 teeth are present.

Correct Answer: B. Babinski ** The Babinski reflex, which is elicited by stroking the bottom of the foot and causing the toes to fan and the big toe to dorsiflex, should be present until the age of 1 year. Persistence of neonatal reflexes might indicate neurological deficits. Incorrect Answers: A. The stepping reflex, in which the infant takes reflexive steps when placed on his or her feet in an upright position, disappears by the age o 4 weeks. C. The extrusion reflex, which causes the infant to spit out food placed on the tongue rather than moving it to the back of the mouth, is absent by the age of 4 months. D. The Moro reflex should disappear at the age of 3 to 4 months. It is an extension of the arms and flexion of the elbows in response to a sudden jarring, followed by flexion and adduction of the extremities.

A nurse is performing a physical assessment on a 6-month-old infant. Which of the following reflexes should the nurse expect to find? A. Stepping B. Babinski C. Extrusion D. Moro

Correct Answer: B. Have the child wear his glasses during the vision screening ** The nurse should assess the child's visual acuity while the child is wearing prescribed glasses. Incorrect Answers: A. The nurse should position the child with his heels on a line that is 10 ft away from the letter chart. C. The nurse should perform this action to assess light perception in newborns. While pupillary constriction can confirm that the anterior portion of the eye vis functioning, it does not verify that the posterior portion of the eye is sending images to the brain. D. The nurse can assess the visual acuity of a child who is unable to read letters using the Tumbling E chart. When using this test, the child is instructed to point in the direction the E is facing. This test is appropriate for a preschooler.

A nurse is performing a visual acuity screening for a school-aged child using the Snellen letter chart. Which of the following actions should the nurse take? A. Position the child 5 ft away from the letter chart B. Have the child wear his glasses during the vision screening C. Observe for pupillary constriction while shining a light into the child's eye D. Instruct the child to point in the direction the letters are facing

Correct Answer: A. The child is able to hop on 1 foot. ** The nurse should expect a 4-year-old child to have the gross motor ability to hop on 1 foot. Incorrect Answers: B. The nurse should expect a 3-year-old child to have the fine motor ability to build a tower of 9 to 10 blocks. C. The nurse should expect a 5-year-old child to have the language ability to identify time-related words like the days of the week. D. The nurse should expect a 6-year-old child to have the cognitive ability to identify left and right.

A nurse is performing a well-child assessment on a 4-year-old child. Which of the following findings should the nurse expect? A. The child is able to hop on 1 foot. B. The child is able to build a tower of up to 6 blocks. C. The child is able to name the days of the week. D. The child is able to identify left and right.

Correct Answer: B. Industry vs. inferiority ** The developmental task of industry vs. inferiority is reflected by a child's level of motivation in relation to personal achievements that build good character during the school-age years (ages 6 to 12 years). Incorrect Answers: A. Initiative vs. guilt is the developmental task of early childhood (ages 3 to 6 years). C. Identity vs. role confusion is the task of the adolescent (ages 13 to 19 years). D. Autonomy vs. shame and doubt is the developmental task of a toddler (ages 12 months to 3 years).

A nurse is performing a well-child assessment on a 7-year-old client who takes great pride in bringing school papers home. The nurse recognizes that this behavior demonstrates which of the following of Erikson's stages of psychosocial development? A. Initiative vs. guilt B. Industry vs. inferiority C. Identity vs. role confusion D. Autonomy vs. shame and doubt

Correct Answer: D. "Your child's weight change is expected for this age group." ** A preschooler should gain about 2 to 3 kg (4.4 to 6.6 Ib) each year. Therefore, the nurse should reassure the parent that this child's weight gain is an expected finding for the age group. Incorrect Answers: A. This weight gain does not indicate a serious problem. It could be a problem if the child had gained twice that amount, for example, or if a previously average-weight child had lost weight. B. The nurse cannot assume inadequate nutrition or poor eating habits without assessing the child's usual intake and overall diet. C. The rate of weight gain typically slows during the preschool years, but height growth continues at a steady rate.

A nurse is performing an annual physical assessment of a preschooler. The parent expresses concern about the child's 1.8 kg (4 lb) weight gain over the past year. Which of the following responses should the nurse make? A. "This amount of weight gain could likely indicate a serious problem." B. "This weight change seems to be the result of poor eating habits." C. "Your child should have gained double this amount in a year." D. "Your child's weight change is expected for this age group."

Correct Answers: A. Observe the parents' actions when feeding the child B. Maintain a detailed record of food and fluid intake *Inappropriate feeding techniques and meal patterns provided by parents can contribute to a child's growth failure. A nutritional goal for this child who has suspected FTT is to correct nutritional deficiencies, which can be identified by recording all food and fluid intake. Incorrect Answers: C. A consistently structured routine of feeding the child at the same time and place is used to promote weight gain. A child who has failure to thrive might not offer feeding cues. D. Caregivers should sit directly in front of the child to maintain a face-to-face position during feeding and promote eye contact. The

A nurse is planning care for a 10-month-old infant who has suspected failure to thrive (FTT). Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Observe the parents' actions when feeding the child B. Maintain a detailed record of food and fluid intake C. Follow the child's cues to time food and fluids D. Sit beside the child's high chair for feedings E. Play music videos during scheduled meal times

Correct Answer: C. Check the bag for stool every 4 hours ** The nurse should check the bag for stool every 4 hours or less to prevent the bag from overfilling and leaking. Stool from an ileostomy is acidic and can cause excoriation of the skin. Incorrect Answers: A. The nurse should allow the infant to lie on his abdomen because the ostomy has no nerves. Therefore, laying on the ostomy will not cause pain. B. The nurse should tuck the ostomy appliance into the infant's diaper to prevent accidental removal. D. The nurse should plan to replace the appliance once a week. Frequently changing the appliance increases the risk of injury to the skin surrounding the stoma.

A nurse is planning care for a 3-month-old infant who has an ileostomy. Which of the following interventions should the nurse include in the plan? A. Avoid laying the infant on his abdomen B. Avoid tucking the appliance into the infant's diaper C. Check the bag for stool every 4 hours D. Replace the appliance every 3 days

Correct Answer: A. Provide thorough skin care ** The nurse should provide thorough skin care for this child who has nephrotic syndrome. Skin care is especially important due to edema and the risk of infection. Incorrect Answers: B. This child is not likely to receive a blood transfusion, which would be indicated for significant blood loss. C. Fluid restriction might be necessary for a child who has nephrotic syndrome. D. The child's diet might require protein, sodium, and fat restrictions, but there is generally no indication for a low-carbohydrate diet.

A nurse is planning care for a 4-year-old child who has nephrotic syndrome. Which of the following actions should the nurse A. Provide thorough skin care B. Test for blood type and cross-match C. Allow ample hydrating fluids D. Maintain a low-carbohydrate diet

Correct Answer: D. Encourage quiet play ** A platelet count of 20,000/mm^3 will predispose the client to excessive bleeding. Quiet play will lessen the client's risk of injury, thereby reducing the chance of hemorrhage. Incorrect Answers: A. Iron is given to a child who has anemia. A platelet count of 20,000/mm^3 is not an indication of an anemic condition. B. Platelets are the blood component associated with clotting. C. RBCS are the blood component responsible for carrying oxygen to body tissues.

A nurse is planning care for a 6-year-old child who is receiving chemotherapy. The child has a highlight platelet count of 20,000/mm^3. Based on this laboratory value, which of the following interventions should the nurse include in the plan of care? A. Provide foods high in iron B. Avoid people who have infections C. Administer PRN oxygen D. Encourage quiet play

Correct Answer: B. Position the child on a cooling blanket and cover her with a sheet ** A cooling blanket will lower the temperature of the blood circulating at the skin's surface. This cooler blood will circulate to the viscera and lower the temperature of the organs and tissues. Heat from the internal organs will be circulated to the skin and dispensed to the cooler outside surface. Incorrect Answers: A. Hyperthermia is caused by external conditions that create more heat than the body can eliminate. The body temperature exceeds the point, which differs from the elevation of the body's actual set point associated with hyperpyrexia (fever). Because of this, antipyretics are not effective in treating hyperthermia. C. The child should be placed in a warm bath. The nurse should gradually add cool water until the water temperature is 1°C (2°F) lower than the child's body temperature. Placing the child in water that is too cool will result in vasoconstriction of the blood vessels on the surface, which will not allow the visceral heat to dissipate to the cooler outside air. D. The nurse should assess the child's temperature every 30 to 60 minutes or continually during the cooling process to prevent hypothermia.

A nurse is planning care for a child who has hyperthermia. Which of the following actions should the nurse take? A. Administer antipyretics to the child every 4 to 6 hr B. Position the child on a cooling blanket and cover her with a sheet C. Place the child in a tub filled with water cooled to 26.7° to 29.4°C (80° to 85°F) D. Assess the child's temperature every 2 hr during the cooling process

Correct Answer: D. Droplet precautions ** The nurse should maintain droplet precautions for a client who has meningococcal meningitis for 24 to 72 hours after the initiation of antibiotic therapy. Disease transmission can occur through large-droplet particles when the client is talking. There is no drainage of infected body fluids with meningitis, so contact precautions are not necessary. Incorrect Answers: A. This type of isolation would be appropriate for diseases such as rubeola, in which transmission can occur via inhalation but there is no chance of transmission through infected body fluids. B. This type of isolation would be appropriate for diseases such as varicella-zoster, smallpox, and tuberculosis, in which there is a potential for transmission by both inhalation and contact with infected body fluids. C. This type of isolation precaution would be appropriate for a client who underwent an allogeneic hematopoietic stem cell transplant.

A nurse is planning care for a child who has meningococcal meningitis. Which of the following isolation precautions should the nurse plan to implement? A. Airborne precautions B. Contact precautions C. Protective environment D. Droplet precautions

Correct Answer: A. Encourage the parents to bring the child's stuffed animal Encouraging parents to bring in a child's favorite stuffed animal may lessen the disruptiveness of hospitalization. Incorrect Answers: B. Children who have autism have difficulty organizing behaviors; therefore, it is best not to give choices. C. Phenytoin is taken by children who have seizure disorders. D. Children who have autism need decreased stimulation and avoidance of auditory or visual distraction. A private room is preferable.

A nurse is planning care for a preschool-age child who has autism and is being admitted to the facility. Which of the following actions should the nurse plan to take? A. Encourage the parents to bring the child's stuffed animal B. Give the child choices when planning daily activities C. Administer phenytoin 3 times per day D. Provide a shared room with another child his age

Correct Answer: C. Initiative vs. guilt ** A preschooler is in the developmental stage of initiative versus guilt. Preschoolers initiate play activities and experience a feeling of guilt if their efforts at independence receive a negative reaction from caregivers. Incorrect Answers: A. The nurse should identify that a school-aged child is in the developmental stage of industry versus inferiority. In this stage, the child takes initiative for learning and doing things well. Support and positive reinforcement foster the child's sense of pride, while a lack of appreciation can lead to a feeling of inferiority. B. The nurse should identify that an infant is in the developmental stage of trust versus mistrust. In this stage, a caregiver's response to the infant's needs builds trust and reassures the infant that his or her needs are being met. A caregiver who is inconsistent or rejecting can cause a feeling of mistrust. D. The nurse should identify that an adolescent is in the developmental stage of identity versus role confusion. In this stage, the adolescent combines his or her various roles and experiences into a personal identity. Failure to integrate these various images can lead to role confusion or uncertainty of identity or goals.

A nurse is planning care for a preschooler who is scheduled for a surgical procedure. The nurse should identify that the preschooler is in which of the following of Erikson's psychosocial stages of development? A. Industry vs. inferiority B. Trust vs. mistrust C. Initiative vs. guilt D. Identity vs. role confusion

Correct Answer: C. Encourage the child to participate in physical activities ** The nurse should encourage the child to remain physically active to promote mobility and joint function. Incorrect Answers: A. The nurse should discourage the child from sleeping during the daytime. Children who have JIA have interrupted sleep patterns. Therefore, the nurse should encourage 30 to 60 minutes of quiet play instead of napping to improve nighttime sleep. B. The nurse should apply moist heat compresses to the child's affected joints or provide a long bath each morning to alleviate stiffness and pain. D. The nurse does not need to limit any specific foods for a child who has JIA. The child should maintain a healthy weight to decrease pressure on joints.

A nurse is planning care for a school-aged child who has juvenile idiopathic arthritis (JIA). Which of the following actions should the nurse include in the plan? A. Encourage the child to sleep for 1 hour each afternoon B. Apply cold compresses to the child's affected joints each morning C. Encourage the child to participate in physical activities D. Limit the child's intake of foods that are high in uric acid

Correct Answer: A. Oral rehydration solution ** The nurse should plan to provide an oral rehydration solution (ORS) to this child who has acute gastroenteritis. ORS promotes the body's reabsorption of water and sodium and is more effective and less traumatic than the administration of IV fluids for the treatment of dehydration due to diarrhea and emesis. Incorrect Answers: B. The nurse should understand that providing a BRAT (bananas, rice, applesauce, and toast or tea) diet is contraindicated for the treatment of acute gastroenteritis because it does not provide sufficient nutrition and electrolytes. C. The nurse should be aware that providing chicken or beef broth is not recommended for the treatment of acute gastroenteritis because broth does not provide the child with adequate carbohydrates and contains high amounts of sodium. D. The nurse should understand that while providing IV fluids can be effective in the treatment of dehydration caused by acute gastroenteritis, oral treatment is more effective, costs less, and is less traumatic for the child.

A nurse is planning care for a toddler who has acute gastroenteritis and was recently admitted. Which of the following should the nurse plan to provide for the child? O A. Oral rehydration solution B. Bananas or applesauce C. Chicken or beef broth D. Hypertonic IV solution

Correct Answer: C. Maintain the child on bed rest ** The nurse should maintain bed rest for this child who is experiencing a vaso-occlusive crisis to minimize energy expenditure and avoid additional oxygen needs. Incorrect Answers: A. Cold compresses are contraindicated because they enhance sickling and vasoconstriction. B. Meperidine is not recommended because this central nervous system stimulant can produce anxiety, tremors, and generalized seizures. D. A child who has sickle cell anemia and is in a vaso-occlusive crisis requires increased fluid intake to prevent sickling.

A nurse is planning care for an adolescent who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions should the nurse include in the plan? A. Apply cold compresses to the child's extremities B. Administer meperidine every 4 hr until the crisis has resolved C. Maintain the child on bed rest D. Decrease the child's fluid intake for 8 hr

Correct Answers: B. Allow 30 min to complete each feeding C. Gradually increase the caloric density of the formula D. Position the infant semi-upright during feedings E. Provide gavage feeding if respiratory rate exceeds 80/min ** The nurse should allow 30 minutes for each feeding. This length of feeding allows adequate intake without causing the infant to get overly fatigued or to lose needed rest time before the next feeding. The nurse should plan to provide the infant with a formula that has increased caloric density. An infant who has heart failure has an increased metabolic rate due to impaired cardiac function. Adding expressed breast milk or enteral nutrition formula or oil to the formula provides the infant with increased calories in a decreased volume of feeding. The nurse should gradually increase the caloric density of the feeding by 2 kcal/oz/day to promote infant tolerance and decrease the risk of diarrhea.

A nurse is planning care for an infant who has heart failure. Which of the following interventions should the nurse include in the plan to meet the nutritional needs of the infant? (Select all that apply.) A. Offer the infant a feeding every 2 hr B. Allow 30 min to complete each feeding c. Gradually increase the caloric density of the formula D. Position the infant semi-upright during feedings U E. Provide gavage feeding if respiratory rate exceeds 80/min

Correct Answer: C. Palpate the abdomen for bladder distension ** A neurogenic bladder is a common complication of a myelomeningocele. Even if the infant is having wet diapers, the nurse should assess bladder distension due to the possibility of incomplete emptying of the bladder. Incorrect Answers: A. The nurse should not place a diaper on the infant until after the defect has been repaired and healed due to the risk of tearing the sac. The nurse should place padding under the infant to absorb urine and stool and provide frequent skin care. B. Povidone-iodine is neurotoxic and should not come into contact with the spinal malformation. D. The nurse should keep the meningocele sac from drying by applying sterile nonadherent dressings moistened with 0.9% sodium chloride every 2 to 4 hours. A dry dressing might stick to the sac and cause tearing.

A nurse is planning care for an infant with an unrepaired myelomeningocele. Which of the following actions should the nurse take? A. Fasten the diaper loosely B. Cleanse the meningeal sac with povidone-iodine daily C. Palpate the abdomen for bladder distension D. Cover the sac with a dry, sterile gauze dressing

Correct Answer: D. Explain the procedure in terms of what the child will feel, see, hear, and taste. ** Teaching for a preschooler should focus on the child's sensory experience. The teaching can also include what the child can do during the procedure. Incorrect Answers: A. Preschoolers are unable to think abstractly or understand concepts that will occur far in the future. B. The nurse should use dolls or stuffed animals to explain the procedure and allow the child to handle the equipment if possible. C. Teaching for a preschooler should be done using simple, familiar terms.

A nurse is planning preoperative teaching for a 5-year-old child. Which of the following interventions should the nurse include? A. Explain the long-term benefits of the procedure. B. Provide diagrams and pictures while explaining the procedure. c. Use correct medical terminology during the teaching session. D. Explain the procedure in terms of what the child will feel, see, hear, and taste.

Correct Answer: C. Use photographs to help explain the procedure ** The nurse should recognize the school-age child's increased language ability and desire for knowledge. The nurse should use photographs and simple diagrams to explain the procedure in an interesting and concrete way that the child can understand. Incorrect Answers: A. The nurse should limit teaching sessions to 10 to 15 minutes for a preschooler but can extend sessions for a school-age child to about 20 minutes. B. The nurse should use correct medical terminology when providing preoperative teaching for this child. D. The nurse should schedule preoperative teaching sessions for a school-age child no more than 1 day prior to the procedure.

A nurse is planning preoperative teaching for a school-age child who is scheduled for cardiac surgery. Which of the following actions should the nurse plan to take when teaching the child? A. Limit teaching sessions to 10 min B. Use simple, concrete terms when giving explanations c. Use photographs to help explain the procedure D. Conduct the teaching session 2 days before the procedure

Correct Answer: A. Ask the child to describe what things were like right before not wanting to go to school ** The nurse should ask the child to describe what things were like before she stopped going to school to help determine whether this behavior is related to a long-term issue or a critical incident that caused intense discomfort. Incorrect Answers: B. The nurse should not use a direct question and ask the child why going to school is no longer fun because the child might not provide an honest answer. C. This statement does not address the cause of the child's unwillingness to go back to school. D. This statement provides false reassurance to the child.

A nurse is planning to assess an 8-year-old child who was brought to the clinic by a parent. The parent reports the child has missed school for 3 weeks and refuses to go back due to "not feeling well." Which of the following actions should the nurse perform during the initial interview with the child? A. Ask the child to describe what things were like right before not wanting to go to school B. Use a direct question and ask the child why going to school is no longer fun C. Tell the child it is okay not to like school, but she has to go back D. Reassure the child that things might not be going well right now, but they will soon improve

Correct Answer: A. Wash and dry the infant's genitalia and perineum thoroughly ** This is the method used to obtain a routine urine specimen of any sort in a child who is not toilet-trained. The skin should be washed and dried to promote the application of the adhesive of the collection device. Incorrect Answers: B. The adhesive on the collection device will not stick to the infant's skin if it is moistened with lubricant. Oil and powder should not be used. C. The nurse may place the infant's penis and scrotum inside the collection bag in order to ensure a snug fit and prevent leaking. D. The urine collector should be checked frequently and removed when urine is obtained. If the infant is active, the adhesive might loosen.

A nurse is planning to collect a specimen from a male infant using a urine collection bag. Which of the following actions should the nurse take? A. Wash and dry the infant's genitalia and perineum thoroughly B. Apply a small coating of water-soluble lubricant to the skin of the infant's perineal area C. Avoid placing the scrotum inside the collection bag D. Wait several hours after positioning the device before checking it

Correct Answer: B. Industry vs. inferiority ** When planning to teach, the nurse should identify that school-age children are attempting to master the developmental task of industry vs. inferiority. During this stage, children enjoy learning new skills and experiencing the sense of accomplishment that comes with mastery of the skill. Incorrect Answers: A. Initiative vs. guilt is the developmental task of a preschool child. C. Trust vs. mistrust is the developmental task of an infant. D. Identity vs. role confusion is the developmental task of a young adult.

A nurse is planning to teach a 9-year-old child who has a new diagnosis of diabetes mellitus. The nurse should identify that school-age children are attempting to master which of the following developmental tasks? A. Initiative vs. guilt B. Industry vs. inferiority C. Trust vs, mistrust D. Identity vs. role confusion

Correct Answer: D. Encourage the child to focus on a recent pleasurable experience ** The nurse should encourage the child to focus on a recent pleasurable experience such as a trip to the zoo, when using the nonpharmacological technique of guided imagery. This technique encourages the child to focus on the pleasurable experience rather than the sensation of pain. The technique can also be combined with relaxation and breathing techniques. Incorrect Answers: A. The nurse should ask the child to find different designs in a kaleidoscope when using the nonpharmacological technique of distraction. B. The nurse should encourage the child to take a deep breath and let their body go limp during exhalation when using the nonpharmacological technique of relaxation. C. The nurse should encourage the child to think about a stop sign when beginning to feel pain when using the nonpharmacological technique of thought-stopping.

A nurse is planning to use guided imagery for an early school-aged child who continues to have mild discomfort following the administration of an analgesic. Which of the following techniques should the nurse plan to use? A. Give the child a kaleidoscope and ask the child to find different designs B. Encourage the child to take a deep breath and let the body go limp on the exhale C. Teach the child to picture a stop sign whenever the pain begins D. Encourage the child to focus on a recent pleasurable experience

Correct Answer: A. Schedule the child for a preoperative visit to the facility ** A preoperative visit to the facility allows the child to observe perioperative processes. This education helps the child feel at ease prior to the surgical procedure. Incorrect Answers: B. After 9 years of age, a child understands concepts of death. The nurse should inform the child that he is taking a "special sleep" not that he is being "put to sleep." Children who have pets might regard being "put to sleep" as experiencing death. C. Reading a cartoon book is developmentally appropriate for a preschool-age child or toddler. Participating in therapeutic play has benefits for those age groups. D. Children need factual information and explanations about what will happen during hospitalizations.

A nurse is preparing a school-age child for a tonsillectomy. Which of the following actions should the nurse take? A. Schedule the child for a preoperative visit to the facility B. Inform the child he will be put to sleep for the procedure C. Read the child a story about a cartoon character having a similar operation D. Tell the child the appointment is to have his throat checked

Correct Answer: B. Give the medication at the side of the infant's mouth ** When administering medications to an infant, a needleless oral syringe or medicine dropper is placed in the side of the mouth (i.e. in the buccal cavity alongside the tongue) to prevent gagging and aspiration. Incorrect Answers: A. Administering the medication to the infant while supine can cause the infant to choke and aspirate. C. Medication should never be mixed into an infant's regular formula to be given through a bottle. This method cannot ensure that all the medication has been administered and may cause the infant not to take the bottle or formula in the future if it becomes associated with an unpleasant taste or activity. D. An infant's nasal passages should never be blocked to promote swallowing of oral medications. Young infants are obligatory nose breathers, and holding the nares closed can increase an infant's distress. This method of administration also increases the risk of aspiration.

A nurse is preparing to administer a liquid medication to an infant. Which of the following actions should the nurse take? A. Administer the medication while the infant is supine B. Give the medication at the side of the infant's mouth C. Add the medication to a full bottle of the infant's formula D. Administer the medication slowly while holding the nares closed

Correct Answer: D. Hold the infant's buttocks together after administering the fluid Because the infant is incontinent, the nurse should hold the buttocks together for a short time to maintain retention of the enema, Incorrect Answers: A. Tap water is hypotonic and can cause a rapid fluid shift and fluid overload. An isotonic solution of 0.9% sodium chloride should be used. B. For an infant, the tubing should be inserted 2.5 cm (1 in) into the rectum for the administration of the enema. C. The infant should be placed in a supine position with the buttocks over a bedpan and the head and back supported by pillows.

A nurse is preparing to administer an enema to a 10-month-old infant. Which of the following actions should the nurse plan to take? A. Administer the enema using room-temperature tap water B. Insert the tubing 7.5 cm (3 in) into the rectum C. Position the infant sitting upright on a bedpan while administering the enema D. Hold the infant's buttocks together after administering the fluid

Correct Answer: A. Vastus lateralis ** The vastus lateralis is a large developed muscle, even in an infant. The muscle can tolerate the volume of the injection, and there are no important nerves or blood vessels in this muscle. Incorrect Answers: B. Receiving an injection at the dorsogluteal site at 2 months of age is contraindicated because the muscle is poorly developed. C. The deltoid has a small muscle mass, and the proximity of the radial and axillary nerves make it suitable for use only after the age of 18 months. D. The abdomen is used for subcutaneous injections.

A nurse is preparing to administer an intramuscular injection to a 2-month-old infant. In which of the following sites should the nurse plan to administer the injection? A. Vastus lateralis B. Dorsogluteal c. Deltoid D. Abdomen 5 cm (2 in) from the umbilicus

Correct Answer: 15

A nurse is preparing to administer diphenhydramine 5mg/kg/day PO divided equally every 8 hr to a school-age child who weighs 50 lb. Diphenhydramine oral solution 12.5 mg/5 mL is available. How many mL should the nurse administer per dose? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

Correct Answer: C. Haemophilus influenzae type B (Hib) and inactivated polio virus (IPV) ** The recommended immunizations for a 2-month-old infant include Hib and IPV. The Hib immunization series consists of 3 to 4 doses, depending on the immunization used. At minimum, it is administered at 2 months, 4 months, and 12 to 15 months of age. The IPV immunization series consists of 4 doses and is administered at 2 months, 4 months, 6 to 18 months, and 4 to 6 years of age. Incorrect Answers: A. The HPV immunization series is started at the age of 11 years, and the hepatitis A immunization series is started at the age of 12 months. B. The first dose of the MMR immunization is administered at 12 to 15 months of age, and the TDAP immunization is administered at 11 to 12 years of age. D. Varicella is not administered to children younger than 12 months, and the LAIV immunization is not administered to children under 2 years of age.

A nurse is preparing to administer recommended immunizations to a 2-month-old infant. Which of the following immunizations should the nurse plan to administer? A. Human papillomavirus (HPV) and hepatitis A B. Measles, mumps, and rubella (MMR) and tetanus, diphtheria, and acellular pertussis (TDAP) C. Haemophilus influenzae type B (Hib) and inactivated polio virus (IPV) D. Varicella (VAR) and live attenuated influenza vaccine (LAIV)

Correct Answer: A. Inactivated poliovirus vaccine (IPV) ** The nurse should plan to administer the fourth dose of the inactivated poliovirus vaccine between 4 and 6 years of age. The first 3 doses are administered between 2 and 18 months of age. Incorrect Answers: B. The nurse should verify that the child received the Hib vaccine at age 2, 4, and 6 months as well as at age 12 to 15 months. This immunization is not routinely administered at 6 years of age. C. The nurse should verify that the child received the pneumococcal conjugate vaccine at 2, 4, 6, and 12 to 15 months of age. This immunization is not routinely administered at 6 years of age. D. The nurse should verify that the child received the HBV vaccine within 12 hours after birth and received additional doses at 1 to 2 months and 6 to 18 months of age. This immunization is not routinely administered at 6 years of age.

A nurse is preparing to administer routine immunizations to a 6-year-old child. In addition to the diphtheria, tetanus, and pertussis (DTAP) vaccine; the measles, mumps, and rubella (MMR) vaccine; and the varicella vaccine, which of the following immunizations should the nurse plan to administer? A. Inactivated poliovirus vaccine (IPV) B. Haemophilus influenzae type B vaccine (Hib) C. Pneumococcal conjugate vaccine (PCV) D. Hepatitis B vaccine (HBV)

Correct Answer: C. Examine the infant's throat at the end of the examination ** The nurse should perform noninvasive assessments first to avoid causing the infant to cry, which can make the remainder of the examination difficult. Incorrect Answers: A. The nurse should pull the infant's pinna downward and toward the back of the head when examining the ears. The ear canal is curved upward until approximately 3 years of age. Pulling the pinna down and back straightens the ear canal and allows easier visualization of the tympanic membrane. B. The nurse should assess the infant's heart rate by auscultating the apical pulse for 1 min. D. The nurse should not measure the blood pressure in an 11-month-old infant. Blood pressure is routinely measured starting at 3 years of age.

A nurse is preparing to assess an 11-month-old infant during a well-child examination. Which of the following actions should the nurse take? A. Pull the infant's pinna up and back when examining the ears B. Palpate and count the infant's radial pulse for 15 seconds C. Examine the infant's throat at the end of the examination D. Check the infant's blood pressure in both arms

Correct Answer: A. Burp the infant at least 2 to 3 times during the feeding ** Infants who have a cleft lip and palate will swallow an increased amount of air during a feeding due to a lack of separation between the oral and nasal cavities. Infants should be burped after every ounce of formula consumed. Incorrect Answers: B. Infants who have a cleft lip and palate are typically "noisy" feeders due to the increased amount of air that is swallowed during a feeding. The nurse should watch the infant carefully for signs of distress during a feeding such as a wrinkled brow, elevated eyebrows, or watering eyes. If these distress signs are noted, the nurse should remove the nipple and allow time for the infant to swallow the formula. C. Formula is expected to appear in the nose of an infant who has a cleft lip and palate due to a lack of separation between the oral and nasal cavities. D. Parents and caregivers should be encouraged to begin feeding the infant as soon as possible. This opportunity enables the caregivers to gain experience and confidence in their ability to feed the infant prior to discharge, which typically occurs before the surgical repair.

A nurse is preparing to feed an infant who has a cleft lip and palate. Which of the following actions should the nurse plan to take? A. Burp the infant at least 2 to 3 times during the feeding B. Remove the nipple from the infant's mouth if swallowing becomes audible C. Stop the feeding if formula appears in the nasal cavity of the infant D. Discourage the parents from participating in the feeding prior to a surgical repair

Correct Answer: D. "The test shows us if your child had a recent strep infection." ** An ASO titer indicates the child had a recent strep infection. When determining a definitive diagnosis for acute glomerulonephritis, this must be documented because the condition is usually the result of this type of infection. Incorrect Answers: A. A therapeutic blood level indicates a medication (e.g. an antibiotic) is effective. B. A rubella titer indicates the presence of measles. C. A serum albumin level is monitored in a child who has nephrotic syndrome.

A nurse is preparing to obtain an antistreptolysin O (ASO) titer from a child who has acute glomerulonephritis. The child's parent asks the nurse to explain the purpose of the test. Which of the following responses should the nurse provide? A. "The test determines the level of antibiotics in your child's blood." B. "The test tells us if your child ever had measles." C. "The test verifies the amount of albumin in your child's blood." D. "The test shows us if your child had a recent strep infection."

Correct Answer: C. Prepare concentrated sucrose for oral administration ** The nurse should provide the newborn with oral sucrose 2 minutes prior to performing the heel puncture. This practice, along with non- nutritive sucking, has been shown to decrease the pain the newborn experiences during the heel puncture. Incorrect Answers: A. Tolmetin is an oral analgesic medication for clients 2 years of age and older. Therefore, the nurse should not administer this medication to the newborn. B. The nurse should apply EMLA cream to the puncture site about 1 hour prior to the procedure. This allows time for the EMLA cream to decrease the pain the newborn experiences during the heel puncture. D. If skin-to-skin contact with a parent is not possible, the nurse should swaddle and rock or hold the infant to decrease the pain that the newborn experiences during the heel puncture. Swaddling the newborn can reduce pain associated with procedures because it mimics the feeling of being in the womb, whereas being placed in an extended position would be uncomfortable for the newborn and would likely

A nurse is preparing to perform a routine heel puncture on a newborn. Which of the following actions should the nurse take? A. Administer tolmetin prior to the procedure B. Apply a eutectic mixture of local anesthetics (EMLA) cream to the newborn's heel after the procedure C. Prepare concentrated sucrose for oral administration D. Place the newborn in an extended position

Correct Answer: C. "I will miss your child's infectious laugh; it always made me smile." ** Expressing personal feelings about the loss of the child can convey empathy and support the grieving parent. Describing the positive impact that the child had, such as making others smile, is a way to share positive memories with the parent. Incorrect Answers: A. Following a traumatic event such as the loss of a child, the nurse should convey empathy and provide emotional support. The nurse should respect the emotional needs of the parent and allow the parent to determine when the funeral home should be contacted. B. The nurse should avoid using trite phrases that belittle the parent's feelings and minimize the impact of the loss. D. Giving a personal opinion such as instructing the parent at this time is nontherapeutic and judgmental and does not take consideration the parent's grief.

A nurse is present at the time of a child's death following a terminal illness. Which of the following statements should the nurse make to the child's parent? A. "If you'll excuse me, l'll go call the funeral home to have them pick up your child." B. "Your child is no longer suffering." C. "I will miss your child's infectious laugh; it always made me smile." D. "You should consider how to share the news of your child's death with her siblings."

Correct Answer: C. Call the poison control center. ** According to evidence-based practice, the nurse should instruct the parents to call the poison control center, which will then identify what further actions the parents should take. Incorrect Answers: A. Giving the toddler milk to drink will depend on the poison that has been ingested. Evidence-based practice indicates that the nurse should take a different action first. B. The parents may need to take the toddler to the emergency department, but this will depend on the poison and amount that has been ingested. Evidence-based practice indicates that the nurse should take a different action first. D. Inducing vomiting will depend on the poison that has been ingested. Evidence-based practice indicates that the nurse should take a different action first. For many poisons, such as corrosives, inducing vomiting can cause additional harm by prompting burns.

A nurse is providing anticipatory guidance about the accidental ingestion of a toxic substance to the parents of a toddler. The nurse should instruct the parents to take which of the following actions first if the child ingests a hazardous substance? A. Give the toddler milk. B. Go to an emergency department. c. Call the poison control center. D. Induce vomiting.

Correct Answer: D. Allow the infant to try finger foods, such as crackers, after 6 months of age. ** The nurse should instruct the caregivers that infants will acquire the coordination to begin self-feeding finger foods at around 6 months of age. Incorrect Answers: A. The nurse should instruct the caregivers to provide the infant with commercial iron-fortified formula or breast milk until 1 year of age. B. The nurse should instruct the caregivers to offer the infant cold fruit juice. Vitamin C enhances the absorption of iron, but heating the juice will destroy the vitamin C content. C. The nurse should instruct the caregivers to introduce new foods individually every 5 to 7 days to ensure the child does not have an adverse reaction to the food.

A nurse is providing anticipatory nutritional guidance for the caregivers of a 5-month-old infant. Which of the following points should the nurse include in the teaching? A. Switch the infant from formula to low-fat cow's milk at 6 months of age. B. Heat fruit juice before offering it to the infant. C. Introduce a new food every other day. D. Allow the infant to try finger foods, such as crackers, after 6 months of age.

Correct Answer: A. Increase the child's protein intake ** The nurse should recommend an increased protein intake for the child who has cystic fibrosis. These children require up to 150% of the recommended daily allowance to meet their nutritional needs. Incorrect Answers: B. The calorie intake for a child who has cystic fibrosis should be increased, not decreased. C. Increasing the child's fiber intake could increase bulk, and malabsorption might occur; therefore, it is not indicated for this child. D. Decreasing the child's salt intake is not indicated for cystic fibrosis.

A nurse is providing dietary teaching to the parent of a child who has cystic fibrosis. Which of the following dietary recommendations should the nurse make? A. Increase the child's protein intake B. Decrease the child's calorie intake C. Increase the child's fiber intake D. Decrease the child's salt intake

Correct Answer: A. Provide a high-fat diet for the toddler ** Children who have cystic fibrosis have impaired intestinal absorption of fat. Therefore, the toddler will require an increased intake of fat. Incorrect Answers: B. The parent does not need to restrict the toddler's intake of sodium. C. The parent should increase the toddler's daily caloric intake. An increase in foods high in folic acid is not required for children who have cystic fibrosis. D. The parent should increase the toddler's daily caloric intake by 110% to 200% to meet increased nutritional needs. Therefore, the toddler should not skip meals.

A nurse is providing dietary teaching to the parent of a toddler who has cystic fibrosis. Which of the following instructions should the nurse include? A. Provide a high-fat diet for the toddler B. Limit the toddler's daily intake of sodium C. Increase the toddler's intake of foods high in folic acid D. Allow the toddler to skip meals when he is not hungry

Correct Answer: C. Cooked carrots ** The nurse should instruct the parent to offer the toddler foods that are low in protein such as cooked carrots and fruits. Incorrect Answers: A. The nurse should instruct the parent to avoid foods high in protein such as whole milk. B. The nurse should instruct the parent to avoid foods high in protein such as ground beef. D. The nurse should instruct the parent to avoid foods high in protein such as eggs.

A nurse is providing dietary teaching to the parent of a toddler who has phenylketonuria. Which of the following foods should the nurse recommend? A. Whole milk B. Ground beef C. Cooked carrots D. Eggs

Correct Answer: C. "I should lightly massage my baby underneath the straps once a day." **The parent should lightly massage the skin under the harness daily to promote circulation. Incorrect Answers: A. The parent should avoid using powders and lotions because they can accumulate in the skin folds and cause irritation. B. The parent should never adjust the length of the straps on the harness. The straps should only be adjusted by the health care provider to ensure prevention of hip extension and adduction. D. The diaper should be placed under the harness to maintain cleanliness.

A nurse is providing discharge teaching for the parent of a newborn who is prescribed a Pavlik harness for developmental dysplasia of the hip. Which of the following responses indicates an understanding of the teaching? A. "I should apply powder to the folds of skin on my baby's knees and thighs." B. "I should adjust the straps on the harness once a week as my baby grows." C. "I should lightly massage my baby underneath the straps once a day." D. "I should place my baby's diaper over the straps of the harness."

Correct Answer: B. "We will notify the doctor right away if he has a fever." ** Infection is a risk after ventriculoperitoneal shunt insertion, especially 1 to 2 months after placement. The parents should report fevers, vomiting, seizure activity, and decreased responsiveness, as these findings can indicate infection. Incorrect Answers: A. The fluid that the shunt redirects from the ventricles to the abdomen is minimal and absorbs readily into the peritoneum. C. Older children should wear a helmet when participating in physically active play to decrease the risk of injury; however, it is not necessary for the parents to place a helmet on this infant. D. Seizures indicate a serious complication such as an infection or shunt obstruction. The parents should notify the provider immediately about any erratic neurological behavior.

A nurse is providing discharge teaching to parents whose infant had a ventriculoperitoneal shunt placement for the treatment of hydrocephalus. Which of the following statements by the parents indicates an understanding of the teaching? A. "We will check his abdomen daily for signs of fluid accumulation." B. "We will notify the doctor right away if he has a fever." C. "We should keep a helmet on him when he's awake." D. "We can expect him to have occasional seizure episodes."

Correct Answer: B. Constant clearing of the throat ** A manifestation of hemorrhage following a tonsillectomy is the constant clearing of blood that is draining in the back of the throat. Therefore, it should be reported to the provider if the adolescent begins constantly clearing the throat following a tonsillectomy. Incorrect Answers: A. Following a tonsillectomy, some secretions can contain old blood. Old blood is a dark brown color, and fresh blood is bright red. Nasal secretions containing dark brown blood should not be reported to the provider because this is an expected finding. C. Following a tonsillectomy, an unpleasant odor from the oral cavity for several days is an expected manifestation. D. Following a tonsillectomy, a low-grade fever for several days is an expected manifestation.

A nurse is providing discharge teaching to the guardian of an adolescent who is postoperative following a tonsillectomy. Which of the following manifestations should the guardian report to the provider? A. Nasal secretions containing dark brown blood B. Constant clearing of the throat c. Unpleasant odor from the oral cavity D. Temperature of 37.7°C (99.8° F) at 48 hr postoperative

Correct Answer: C. Apply antibacterial ointment to the infant's penis once per day ** The nurse should instruct the guardian to apply an antibacterial ointment to the infant's penis once daily to decrease the risk of infection. Incorrect Answers: A. The nurse should instruct the guardian to avoid clamping the catheter at any time. B. The nurse should instruct the guardian to avoid giving the infant tub baths until the catheter and stent are removed and bathing is approved by the provider. D. The nurse should instruct the guardian to increase the infant's fluid intake.

A nurse is providing discharge teaching to the guardian of an infant following a hypospadias repair. Which of the following instructions should the nurse include? A. Clamp the infant's catheter for 30 minutes each day B. Give the infant a tub bath once per day C. Apply antibacterial ointment to the infant's penis once per day D. Decrease the infant's fluid intake for 3 days

Correct Answer: C. "I will inspect my child's mouth every day for sores." ** A child who has leukemia is at an increased risk of mucositis; therefore, the parent should inspect the child's mouth daily for lesions or ulcerations. Incorrect Answers: A. The parent should avoid taking rectal temperatures to prevent trauma to the child. B. A child who has leukemia will have a compromised immune system and should not receive the MMR vaccine. D. The nurse should advise the parents to avoid any activities that could cause injury or bleeding, such as riding bicycles or climbing playground equipment.

A nurse is providing discharge teaching to the parent of a school-aged child who has leukemia and is receiving chemotherapy. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will take my child's rectal temperature daily." B. "I will make sure my child gets his MMR vaccine this week." C. "I will inspect my child's mouth every day for sores." D. "I will allow my child to ride his bicycle tomorrow."

Correct Answer: D. Keep the child away from people who have an infection ** Children who have nephrotic syndrome are at increased risk for infection and should avoid contact with people who have infections. Incorrect Answers: A. The nurse should instruct the parents to restrict the child's sodium intake and, in severe cases, restrict fluids. A child who has acute glomerulonephritis should have a restricted potassium intake. B. Corticosteroids are the first-line treatment for children who have nephrotic syndrome. C. A child who has nephrotic syndrome should be weighed at home daily to determine the effectiveness of the therapy.

A nurse is providing discharge teaching to the parents of a child who has nephrotic syndrome. Which of the following instructions should the nurse include in the teaching? A. Restrict the child's potassium intake B. Administer acetaminophen to the child twice daily C. Weigh the child once each week D. Keep the child away from people who have an infection

Correct Answer: A. Begin after the extrusion reflex has diminished. ** The nurse should explain that the extrusion reflex results in food being pushed out of the mouth instead of being swallowed. The tongue extrusion reflex diminishes after 4 months of age. Incorrect Answers: B. Prior to 4 to 6 months of age, the infant's digestive tract is too immature to digest complex nutrients and has increased sensitivity to potential food allergens. Solid foods should not be introduced before 4 to 6 months of age. C. Tooth eruption occurs at 8 months of age, on average. Solids can be introduced before the eruption of the first tooth, as infants do not have to chew the initial foods introduced. D. The parents should not add corn syrup or honey to the infant's food. Both corn syrup and honey may contain botulism spores, which can lead to infantile botulism,

A nurse is providing education about the introduction of solid foods for the parent of an infant. Which of the following instructions should the nurse include? A. Begin after the extrusion reflex has diminished. B. Introduce solids between 2 and 3 months of age. c. Wait until the infant's first tooth erupts. D. Add a sweetener such as light corn syrup to bland foods.

Correct Answer: B. Vocabulary of 10 or more words ** At 18 months, children typically have a vocabulary of 10 or more words. Incorrect Answers: A. A 2-year-old child can state his/her name and typically refers to self by name as opposed to using the correct pronoun. C. A 2-year-old child is typically able to follow and complete simple commands. D. Toddlers typically cannot name a color until they have reached 30 months of age.

A nurse is providing education for a group of parents about toddler language development during a well-child visit. Which of the following findings should the parent expect in an 18-month-old toddler? A. Ability to refer to self by name B. Vocabulary of 10 or more words C. Following simple directional commands D. Naming a single color

Correct Answer: A. "Explain what you are doing to the infant while providing care." ** The nurse should instruct the family that exposing the infant to expressive speech is the foundation for the development of expressive skills (the ability to make others understand needs and thoughts) and receptive skills (the ability to understand spoken words). Incorrect Answers: B. Pacifier use is associated with an increased incidence of otitis media and does not encourage language development. The nurse should instruct the parents to discourage pacifier use after 6 months of age. C. Chewing and jaw muscle development does not promote language development. The nurse should instruct the family that hot dogs and carrots are choking hazards and should not be given to infants. D. The nurse should instruct the family that leaving a television playing in the child's room can disrupt sleep patterns and should be avoided.

A nurse is providing education for the family of a 6-month-old infant about ways to stimulate language development. Which of the following instructions should the nurse include? A. "Explain what you are doing to the infant while providing care." B. "Promote fine-motor development of the tongue by offering a pacifier several times each day." C. "Exercise jaw muscles with foods that require chewing, such as hot dogs and carrots." D. "Leave a television playing in the child's room during nap time."

Correct Answer: C. "I will help my child to blow bubbles during the injection." ** Providing distraction, such as helping or allowing a child to blow bubbles while receiving an injection, is a technique that can minimize pain and discomfort for the child. Incorrect Answers: A. A child who receives an MMR immunization is not considered contagious. The child can play with other children as usual. B. MMR and varicella immunizations can be administered during the same visit by using separate syringes and different injection sites. If not administered during the same visit, they must be administered at least 1 month apart from each other. D. MMR immunizations are administered subcutaneously; therefore, the nurse would not expect any drainage from the injection site.

A nurse is providing education to the parent of a toddler who is about to receive an MMR (measles, mumps and rubella) immunization. Which of the following statements by the parent indicates an understanding of the teaching? A. "My child should not play with other children for 2 days." B. "I will need to return in 2 weeks for my child to receive the varicella immunization." C. "I will help my child to blow bubbles during the injection." D. "My child may have some drainage from the injection site."

Correct Answer: B. Eliminate the use of a straw when offering fluids ** Straws can accidentally injure the surgical site and cause bleeding. Their use should be avoided in the immediate postoperative period. Incorrect Answers: A. Dairy products should be avoided in the immediate postoperative period because they coat the mouth and throat and can induce coughing. Coughing can lead to increased bleeding from the operative area. C. The nurse should offer an ice collar to provide nonpharmacological pain relief. D. The pressure from nose blowing can increase bleeding from the surgical site.

A nurse is providing immediate postoperative care for a preschooler who had a tonsillectomy. Which of the following actions should the nurse take? A. Offer ice cream or pudding when the child is fully awake B. Eliminate the use of a straw when offering fluids C. Apply a heating pad to the neck area D. Instruct the child to blow his nose to clear bloody secretions

Correct Answer: C. Scrambled eggs ** A client who has celiac disease should be on a gluten-free diet and should avoid foods containing barley, oat, rye, and wheat; therefore, scrambled eggs are an appropriate breakfast item for the nurse to recommend to the client. Incorrect Answers: A. Gluten is found primarily in wheat and rye, but it is also found in smaller quantities in barley and oats; therefore, plain flour pastries are an inappropriate breakfast item for the nurse to recommend to the client. B. Wheat cereal is an inappropriate breakfast item for the nurse to recommend to this client. D. Rye toast is an inappropriate breakfast item for the nurse to recommend to this client.

A nurse is providing nutritional teaching to an adolescent client who has celiac disease. Which of the following breakfast foods should the nurse recommend? A. Plain flour pastry B. Wheat cereal C. Scrambled eggs D. Rye toast

Correct Answer: C. "I will fold my baby's diaper away from the incision." ** To prevent infection, the parent should be able to describe and demonstrate proper folding of the diaper to protect the surgical incision from contamination. Incorrect Answers: A. Crying can increase intra-abdominal pressure; however, this does not result in bulging at the site. B. The parent should not use a belly band because they can lead to bowel strangulation. D. The parent should sponge-bathe the infant until the postoperative visit when the provider removes the dressing.

A nurse is providing postoperative teaching to the parent of a 3-month-old infant who is recovering from an umbilical hernia repair. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will expect the site to bulge when my baby cries." B. "I will place a belly band around my baby's abdomen." C. "I will fold my baby's diaper away from the incision." D. "I will bathe my child in the bathtub daily."

Correct Answer: C. Use a doll with tubes and an incision to explain the surgery. ** Play involving visual and interactive approaches is appropriate for a school-age child's level of understanding. Incorrect Answers: A. School-age children should have preoperative teaching up to 1 day before the procedure to allow the child time to process the information and form questions. B. Teaching sessions should last no longer than 20 minutes for a school-age child. D. Concerns about changes to body image and the presence of a scar are important to adolescents rather than school-age children.

A nurse is providing preoperative education for an 8-year-old child prior to cardiac surgery. Which of the following actions should the nurse take? A. Provide education for the child immediately before the surgery. B. Plan a teaching session that will last no longer than 60 min. C. Use a doll with tubes and an incision to explain the surgery. D. Discuss methods to cover the scar once healing has occurred.

Correct Answer: B. Muscle weakness ** Muscle weakness is a common adverse effect of baclofen. Other common adverse effects include dizziness, drowsiness, and nausea. Incorrect Answers: A. Bradycardia is not an adverse effect of baclofen. This medication can cause hypotension. C. Diarrhea is not an adverse effect of baclofen. This medication can cause constipation. D. Dry skin is not an adverse effect of baclofen. This medication can cause increased sweating.

A nurse is providing teaching about baclofen to the guardian of a toddler who has cerebral palsy. Which of the following adverse effects should the nurse include? A. Bradycardia B. Muscle weakness C. Diarrhea D. Dry skin

Correct Answer: B. "I will encourage my child to participate in sports." ** The parent should encourage the child to remain physically active because this promotes lung expansion and air exchange. Incorrect Answers: A. The client's immunization schedule must be kept. Vaccine-preventable illnesses such as influenza and pneumonia can be dangerous for a child who has asthma. C. The parent should not administer aspirin to a child who has asthma due to the risk of Reye syndrome and an increased risk of a hypersensitivity response to aspirin. D. Approximately two-thirds of children with asthma continue to have manifestations into adulthood.

A nurse is providing teaching about disease management to the parent of a preschooler who has a new diagnosis of asthma. Which of the following parent statements indicates an understanding of the teaching? A. "My child should not receive live virus vaccines." B. "I will encourage my child to participate in sports." C. "I will give my child aspirin when she has a fever." D. "My child will outgrow asthma by adulthood."

Correct Answer: C. "Your mucus is thick because cystic fibrosis interferes with how your glands work." ** A 9-year-old child should understand that the production of thick mucus is a part of the disease process. Incorrect Answers: A. School-age children do not engage in abstract thought and reasoning because they are unable to grasp the reality of long-term consequences. This statement would be appropriate for an adolescent client. B. School-age children want to understand how things work. Any explanation should include appropriate scientific and medical terminology. D. This statement does not explain the pathophysiology of cystic fibrosis, why it interferes with sleep, or how the medicine will help.

A nurse is providing teaching about disease-management strategies to a 9-year-old client who has cystic fibrosis. Which of the following statements should the nurse include? A. "Thorough and effective pulmonary clearance can help prevent the need for a lung transplant when you get older." B. "You should eat these kinds of foods because they will help you grow big and strong." C. "Your mucus is thick because cystic fibrosis interferes with how your glands work." D. "Your medication follows a certain schedule to help you sleep better."

Correct Answer: B. 1/2 cup cooked pinto beans ** The nurse should recommend foods high in fiber for a child who has chronic constipation. A half cup of cooked pinto beans contains approximately 5 g of fiber. Therefore, the nurse should instruct the guardian to include this food in the child's diet. Incorrect Answers: A. A half cup of whole milk contains no fiber. C. One cup of green leaf lettuce contains no fiber. D. One cup of apple juice contains no fiber.

A nurse is providing teaching about foods high in fiber to the guardian of a child who has chronic constipation. Which of the following foods should the nurse recommend? A. 1/2 cup whole milk B. 1/2 cup cooked pinto beans C.1 cup green leaf lettuce D. 1 cup apple juice

Correct Answer: A. Encourage the adolescent to participate in non-contact sports ** The nurse should instruct the guardian that the adolescent should be allowed to participate in non-contact sports such as walking, bowling, and golf. Contact sports may be allowed if the adolescent wears protective gear and receives routine recombinant factor VIII infusions. Incorrect Answers: B. The nurse should instruct the parent to provide the adolescent with a soft-bristled toothbrush or sponge to decrease the risk of bleeding. C. The nurse should instruct the parent to administer acetaminophen for pain. Aspirin increases the risk of bleeding. D. The nurse should instruct the parent to provide an electric razor for shaving to decrease the risk of bleeding.

A nurse is providing teaching about home care to the guardian of an adolescent who has hemophilia. Which of the following pieces of information should the nurse provide? A. Encourage the adolescent to participate in non-contact sports B. Provide the adolescent with a firm-bristled toothbrush C. Administer aspirin to the adolescent for episodes of pain D. Provide disposable razors to the adolescent for shaving

Correct Answer: A. "Monitor the color of your child's toes every 4 hours 24 hours." ** The nurse should instruct the parent to monitor the color of the child's toes every 4 hours to check for alterations in perfusion. The nurse should instruct the parent to notify the provider if the child's toes are discolored or cool to the touch. Incorrect Answers: B. The nurse should instruct the parent not to insert anything into the cast to avoid injury to the skin, which can cause infection. The parent should blow cool air into the cast with a hair dryer or fan if the child experiences itching. C. The nurse should instruct the parent that the fiberglass cast will dry within 30 minutes. Casts made from plaster take up to 72 hours to dry. D. The nurse should instruct the parent that the cast must stay dry at all times. The parent should cover the cast with a plastic bag before the child showers or bathes and assist the child as necessary to ensure the cast stays dry when bathing.

A nurse is providing teaching about home care to the parent of a child who has a newly applied fiberglass leg cast. Which of the following statements should the nurse include? A. "Monitor the color of your child's toes every 4 hours for 24 hours." B. "Your child can scratch the skin inside the cast with a small wooden ruler." C. "Expect the cast to remain damp for 72 hours." D. "You can take your child swimming and give baths as usual."

Correct Answer: D. Leave the zinc oxide ointment intact and reapply as necessary during diaper changes ** Zinc oxide can be applied as a barrier ointment to areas that are reddened or open and moist. While removing the waste material, zinc oxide should be left in place as much as possible during a diaper change. More ointment can be applied as needed. The ointment can be removed, if necessary, by applying mineral oil to the area and gently wiping. Incorrect Answers: A. Healthy and slightly irritated skin can be exposed to air to maximize drying and to prevent dermatitis. However, hair dryers and heat lamps have been shown to cause burns and should not be used. B. Superabsorbent disposable diapers should be used to reduce wetness on the skin when diaper dermatitis is present. These diapers prevent the mixing of urine and stool, which increases the occurrence of dermatitis. C. Over-washing of the skin, especially with perfumed soaps or wipes, can be irritating and increase the risk for the development of

A nurse is providing teaching about home care to the parents of an infant who has diaper dermatitis. Which of the following instructions should the nurse include? A. Dry the affected area with a hair dryer on the low setting twice per day B. Use cloth diapers washed in a low-residue detergent C. Wash the genital area vigorously with each diaper change D. Leave the zinc oxide ointment intact and reapply as necessary during diaper changes

Correct Answer: A. Remove bibs before the infant goes to sleep ** The nurse should instruct the parent to remove bibs prior to the infant sleeping to decrease the risk of strangulation. Incorrect Answers: B. The nurse should instruct the parent to dress the infant in a 1-piece sleep sack and avoid using blankets to decrease the risk of suffocation. C. The nurse should instruct the parent to avoid placing the infant in direct sunlight for more than 2 to 3 minutes at a time. If the infant will be exposed to sunlight for a longer period, the parent should cover any exposed areas of skin. D. The nurse should instruct the parent to set the hot water heater to no more than 49°C (120°F) to prevent burn injuries.

A nurse is providing teaching about home safety to the parent of a 2-month-old infant. Which of the following information should the nurse include? A. Remove bibs before the infant goes to sleep B. Cover the infant with a lightweight blanket at bedtime C. Place the infant in direct sunlight for at least 10 minutes each day D. Set the hot water heater to 60°C (140°F)

Correct Answer: A. "Initial vaccines should be administered between birth and 2 weeks of age." ** The first dose of the hepatitis B vaccine should be administered within the first 2 weeks after birth. The dose should be given before discharge from the hospital if the mother is hepatitis B surface antigen (HBSAg) negative. Incorrect Answers: B. If a client receives an initial dose in a series but misses a subsequent dose, the client will not need to begin the series again. The client should receive the missed dose as soon as possible. C. Allergic reactions to vaccines are most often caused by the inactive parts of the vaccine, which are used to enhance the effectiveness of the vaccine. Examples of inactive ingredients that might cause an allergic reaction include purified culture medium proteins such as egg and antibiotics such as neomycin. D. A vaccination does not need to be postponed for minor illnesses such as a common cold. A rectal temperature of 37.5°C (99.5 F) is

A nurse is providing teaching about immunization schedules to the parents of a newborn who is 1 week old. Which of the following pieces of information should the nurse include in the teaching? A. "Initial vaccines should be administered between birth and 2 weeks of age." B. "Your child will need to begin the vaccination series over again if subsequent doses in the series are missed." C. "An allergic reaction to a vaccine is due to the active ingredient in the vaccine." D. "A vaccination should be postponed if your child has a rectal temperature of 99.5°F and head congestion."

Correct Answer: C. "This medication might cause nausea." ** The nurse should instruct the adolescent that nausea is an adverse effect of oxycodone. Other adverse effects include dizziness, sedation, and confusion. Incorrect Answers: A. The nurse should instruct the adolescent that constipation is a common adverse effect of oxycodone. B, The nurse should instruct the adolescent that this medication can cause orthostatic hypotension. Therefore, the adolescent should change positions slowly. D. The nurse should instruct the adolescent that this medication can cause dry mouth.

A nurse is providing teaching about oxycodone to an adolescent who is experiencing a vaso-occlusive crisis. Which of the following pieces of information should the nurse include? A. "This medication can cause diarrhea." B. "This medication can cause an increase in blood pressure." C. "This medication might cause nausea." D. "This medication can cause an increase in salivation."

Correct Answer: C. "Put all cleaning supplies in a locked cabinet." ** Parents should lock cleaning supplies to promote the safety of toddlers. Toddlers are very inquisitive and are able to open most unlocked cabinet doors without difficulty. Incorrect Answers: A. A toddler is able to climb and can obtain many things that are out of reach. Placing medications on a high counter does not ensure the safety of the toddler. B. Not all plants are poisonous. Parents should remove any plants that are poisonous. D. A toddler should not eat out of ceramic items due to the high source of lead content.

A nurse is providing teaching about poisoning prevention to a group of parents with toddlers. Which of the following statements should the nurse make? A. "Keep medications on a counter that is out of reach of the toddler." B. "Do not keep live plants in the house." C. "Put all cleaning supplies in a locked cabinet." D. "Allow your child to eat from his or her favorite ceramic bowls."

Correct Answer: B. "Keep hair off your forehead." ** Hair and scalp care can provide relief from the manifestation of acne. Frequent shampooing and keeping hair away from the face can improve acne. Incorrect Answers: A. Abrasive skin agents such as exfoliating cleansers can worsen acne and cause trauma to the skin. Only gentle skin cleansers should be used. C. Tetracycline should be taken on an empty stomach to improve the absorption of the medication. D. The nurse should instruct the client not to squeeze or pick acne lesions. Squeezing acne lesions ruptures glands and causes sebum to spread into the skin, which increases inflammation.

A nurse is providing teaching for a 14-year old client who has acne. Which of the following instruction should the nurse include? A. "Use an exfoliating cleanser." B. "Keep hair off your forehead." C. "Take tetracycline after meals." D. "Squeeze acne lesions as they appear."

Correct Answer: C. Immediately after the child wakes up in the morning ** The nurse should instruct the parent to perform the tape test as soon as the child wakes up in the morning and before the child bathes or uses the restroom. The test should be repeated for 3 mornings in a row. Incorrect Answers: A. The nurse should instruct the parent that the tape test should be performed before the child has a bowel movement so that pinworm eggs, which would be removed during defecation, can be collected. B. The nurse should instruct the parent to provide the child with a usual diet. It is not necessary to offer a clear liquid diet prior to performing the tape test. D. The nurse should instruct the parent that the tape test should be performed before the child bathes so that pinworm eggs on the perianal area can be collected and not washed away.

A nurse is providing teaching for a parent about pinworm testing. At which of the following times should the nurse advise the parent to perform the tape test? A. Immediately after the child has a bowel movement B. After being on a clear liquid diet for 24 hours C. Immediately after the child wakes up in the morning D. After soaking for 20 minutes in a warm bath

Correct Answer: D. "You will be able to participate in physical exercises." ** Physical exercise is important for the maintenance of joint mobility and muscle strengthening. Participation in non-contact sports and the use of protective equipment such as knee pads are encouraged, although high-impact athletic activities such as karate should be avoided. Incorrect Answers: A. Passive range-of-motion exercises are not done after a bleeding episode because rebleeding can occur. Active motion is best to allow activity to be tailored to the child's pain level. B. A manifestation of hemophilia A is hemarthrosis (bleeding into a joint capsule). This can result in numbness, tingling, or pain, along with discoloration, warmth, and swelling of the affected joint. The nurse should instruct the child to rest the joint, elevate it above the level of the heart, and apply ice to decrease the rate of bleeding into the joint capsule. C. Intracranial hemorrhage is a leading cause of death in clients who have hemophilia A. The nurse should instruct the child to avoid the use of aspirin because it has antiplatelet properties that can increase bleeding.

A nurse is providing teaching to a 12-year-old client who is recovering from an acute episode of hemophilia A. Which of the following statements should the nurse include in the teaching? A. "Have your parent stretch and move your legs for you." B. "Apply heat to joints that become painful, stiff, and swollen." C. "Take aspirin at the first sign of a headache." D. "You will be able to participate in physical exercises."

Correct Answer: B. "I should check my blood glucose levels more often when I am sick." ** Blood glucose levels should be checked every 3 hours during illness for a client who has type 1 diabetes mellitus, even if the client consumes fewer calories than usual. Hyperglycemia often occurs with an infection, requiring additional doses of insulin. Incorrect Answers: A. The client is at risk for hypoglycemia between meals due to the release of insulin into the bloodstream. Therefore, snacks are necessary to maintain blood sugar levels. Total caloric needs and distribution of calories are based on activity patterns and should guide snack choices. C. Exercise lowers blood glucose levels and is encouraged. Restrictions on exercise are not necessary for this client. Activity level and type of exercise need to be considered when determining insulin dosing, the site of insulin injection, and carbohydrate intake. D. Shakiness, difficulty concentrating, headaches, emotional lability, and hunger are all indications of hypoglycemia. The client should let someone know about these signs and should consume 10 to 15 g of simple carbohydrates such as sugar, followed by complex carbohydrates

A nurse is providing teaching to a 13-year-old client who has type 1 diabetes mellitus. Which of the following client statements indicates an understanding diabetes mellitus management? A. "I will need to avoid snacks between meals." B. "I should check my blood glucose levels more often when I am sick." C. "I will need to limit my exercise to 1 hour per day." D. "I should consume 30 g of simple carbohydrates if I feel shaky."

Correct Answer: C. "I will wash my child's clothes in hot water." ** The parent should wash the child's clothes in hot water to kill bacteria. The parent should also keep the child's towels and washcloths separate from those of other members of the household. Incorrect Answers: A. Impetigo is a bacterial infection of the skin caused by staphylococci or streptococci bacteria. B. Impetigo is spread via direct contact and is contagious from the time of initial appearance of lesions until all lesions have healed. D. Impetigo does not cause the formation of antibodies that prevent reinfection. Therefore, the child can get impetigo again in the future.

A nurse is providing teaching to a parent of a preschooler who has impetigo. Which of the following statements by the parent indicates an understanding the teaching? A. "Impetigo is caused by a virus." B. "Impetigo is contagious for 48 hours after vesicles rupture." C. "I will wash my child's clothes in hot water." D. "My child now has immunity against impetigo."

Correct Answer: D. Leave the medicated shampoo on the scalp for 5 to 10 minutes ** The nurse should instruct the parent to use a shampoo made of 2% ketoconazole or 1% selenium sulfide for the treatment of tinea capitis. For the shampoo to be effective, the parent should leave it on the child's scalp for 5 to 10 minutes prior to rinsing. Incorrect Answers: A. The nurse should instruct the parent to use aluminum acetate solution compresses for the treatment of lesions caused by herpes simplex virus type 1 or for tinea pedis. B. The nurse should instruct the parent that tinea infections are caused by fungi and require antifungal treatments and medications. C. The nurse should instruct the parent to seal non-washable toys in a plastic bag for 2 weeks for the treatment of pediculosis.

A nurse is providing teaching to a parent of a preschooler who has tinea capitis. Which of the following instructions should the nurse include in the teaching? A. Apply aluminum acetate solution compresses to the lesions B. Apply hydrocortisone cream to the lesions twice daily C. Seal nonwashable toys in a plastic bag for 2 weeks D. Leave the medicated shampoo on the scalp for 5 to 10 minutes

Correct Answer: C. "Keep the cast above the level of your heart." ** Immediately following the injury (and for at least the first 48 hours), the child should keep the affected limb above the level of the heart to help prevent edema and pain and to promote venous return. Incorrect Answers: A. The child should not insert any objects between the cast and the skin, as scratches or abrasions could lead to infection. B. The child should rest and avoid strenuous activities but should use the muscles of the leg and the joints above and below the cast. D. Fiberglass casts do not deteriorate as much as plaster casts do when wet, but the child should keep the cast dry. Wet cotton batting stocking net inside the cast will absorb water and could lead to skin breakdown.

A nurse is providing teaching to a school-aged child who just had a fiberglass cast application following a lower-extremity fracture. Which of the following instructions should the nurse give the child and his parents about care during the first 48 hr? A. "Use a toothbrush to scratch under the cast if your skin itches." B. "Avoid moving your leg and the joints above and below the cast." C. "Keep the cast above the level of your heart." D. "Clean soil from the cast with soapy water."

Correct Answer: C. "Attend school regularly." **The nurse should encourage this adolescent with idiopathic arthritis to attend school. The adolescent should attend school even on days when joint pain or stiffness occurs. Incorrect Answers: A. The client should apply moist heat to relieve joint pain and stiffness. B. Opioid pain medications are not routinely prescribed for pain associated with juvenile idiopathic arthritis. The nurse should instruct the client to take NSAIDS on a routine schedule to maintain adequate therapeutic levels. D. There is no "arthritis diet" or certain foods for the adolescent to avoid to decrease symptoms of arthritis. However, to avoid excessive weight gain, the client should monitor and match the caloric intake to individual energy needs.

A nurse is providing teaching to an adolescent client who has juvenile idiopathic arthritis. Which of the following instructions should the nurse include in the teaching? A. "Apply cold compresses to relieve your joint pain." B. "Take opioids routinely." C. "Attend school regularly." D. "Adhere to an arthritis diet."

Correct Answer: B. "I can take my brace off for about an hour daily to shower." ** The nurse should instruct the child to wear the brace for 23 hours each day and only to remove it for showering or participating in physical therapy. Incorrect Answers: A. The child should wear the brace for 23 hours each day. At night, the child might be prescribed a bending brace that confines the spine to an over-corrected position. C. The nurse should instruct the adolescent to avoid loosening the straps of the brace if rubbing occurs because this can decrease compression and contraction. D. The brace should be worn over a t-shirt to prevent the plastic pads from touching the skin and causing excoriation.

A nurse is providing teaching to an adolescent who has scoliosis and a new prescription for a Boston brace. Which of the following responses by the adolescent indicates an understanding of the teaching? A. "I can take my brace off to sleep every night at bedtime." B. "I can take my brace off for about an hour daily to shower." C. "I should loosen the straps on my brace if it is rubbing against my skin." D. "I should place the pads of the brace against my skin with at-shirt over them."

Correct Answer: A. Hip Vigorous exercise can enhance the absorption of injected insulin from an involved extremity. ** When participating in vigorous exercise that involves both the arms and legs, the client should use a hip as the insulin injection site. Incorrect Answers: B. Basketball involves both the arms and legs. Therefore, the client should avoid making injections in the upper arms during basketball competitions. C. Basketball involves both the arms and legs. Therefore, the client should avoid making injections in the thighs during basketball competitions. D. The lower leg is not a recommended injection site for insulin. Insulin is administered subcutaneously into adipose or fat tissue over a muscle. Recommended injection sites for insulin are the abdomen, hips, buttocks, upper arms and thighs. When participating in vigorous

A nurse is providing teaching to an adolescent who was recently diagnosed with type 1 diabetes mellitus. Which of the following insulin injection sites should the nurse recommend that the client use during basketball competitions? A. Hip B. Upper arm C. Thigh D. Lower leg

Correct Answer: C. "We can help our child by structuring our daily routine." ** Children who have autism spectrum disorder benefit from a structured routine. This environment can minimize the anxiety the child might have with sudden schedule changes and socialization requirements and satisfy a preference for ritualistic behavior. Incorrect Answers: A. Donepezil might slow the progression of early onset Alzheimer's disease but is not indicated for autism spectrum disorder. B. Children with autism spectrum disorder have a limited interest in others and struggle with interpersonal interaction; therefore, individual therapy with a consistent caregiver is often preferred. D. There is no evidence that prematurity causes autism spectrum disorder.

A nurse is providing teaching to the family of a child who has autism spectrum disorder. Which of the following statements indicates that the family understands the teaching? A. "Donepezil might slow the progression of the disorder." B. "My child will prefer group therapy with other children." c. "We can help our child by structuring our daily routine." D. "Our child probably has this condition as a result of prematurity."

Correct Answer: B. "Use an oral syringe to measure your infant's medicine accurately." ** An oral syringe is the best method for accurately measuring small amounts of liquid medications. Additionally, the syringe allows the caregiver to deposit small amounts of the medication along the side of the infant's tongue to decrease the risk of aspiration. Incorrect Answers: A. Mixing the medication into the infant's formula might prompt the infant to refuse to drink formula in the future. Medications should only be diluted in nonessential liquids. C. An infant should be held in a semi-reclining position during the administration of oral medications to decrease the risk of aspiration. D. Paper cups can easily collapse and might not allow complete administration of thicker liquids. Therefore, they should not be used for dispensing liquid oral medications.

A nurse is providing teaching to the guardian of a 9-month-old infant who has a new prescription for an oral liquid medication. Which of the following points should the nurse include in the teaching? A. "Mix the medication into a small amount of your infant's formula to disguise the taste." B. "Use an oral syringe to measure your infant's medicine accurately." C. "Position your infant supine when administering the medication." D. "Assist your infant with drinking the medicine from a small paper cup."

Correct Answer: B. Instruct the child to walk the bike through intersections ** The child should walk the bike through intersections and crosswalks to decrease the risk of injury. Incorrect Answers: A. The child should ride a bike with the flow of traffic to decrease the risk of injury. C. The child should ride a bike that is t appropriate size to prevent injuries. The balls of the child's feet should be on the ground when the child sits on the bicycle seat. D. The bike helmet should not obstruct the child's eyes or ears to decrease the risk of injury.

A nurse is providing teaching to the guardian of a child about bicycle safety. Which of the following pieces of information should the nurse include? A. Instruct the child to ride against the flow of traffic B. Instruct the child to walk the bike through intersections C. Provide a larger bike that the child will be able to grow into D. Ensure the child's helmet covers the ears

Correct Answers: A. "My child will likely be irritable for the next few weeks." C. "I will ensure my child does not receive any live vaccines for at least 18 months." D. "I will keep a record of my child's temperature until she has no fever for several days." ** A child who is diagnosed with Kawasaki disease will likely be irritable for up to 2 months. A child who has Kawasaki disease receives high doses of gamma globulin during the initial phase, which might result in the inability to produce adequate antibodies in response to a live vaccine; therefore, these vaccines should be delayed for 11 months. Also, the temperature of this child who has Kawasaki disease should be recorded until she has been afebrile for several days. Incorrect Answers: B. Peeling of the skin of the hands and feet is expected for a child who has Kawasaki disease. The peeling does not cause any pain and

A nurse is providing teaching to the guardian of a child who has Kawasaki disease. Which of the following statements by the guardian indicates an understanding of the teaching? (Select all that apply.) A. "My child will likely be irritable for the next few weeks." B. "I will notify my child's doctor if the skin on her hands or feet begins to peel." C. "I will ensure my child does not receive any live vaccines for at least 18 months." D. "I will keep a record of my child's temperature until she has no fever for several days." O E. "My child will have joint stiffness primarily at the end of the day."

Correct Answer: C. Speak at the child's eye level ** The nurse should instruct the guardian to speak at the child's eye level and ensure there is adequate lighting on the speaker's face to facilitate lip-reading and communication. Incorrect Answers: A. The nurse should instruct the guardian to avoid exaggerating the pronounciation of words because this can decrease understanding. B. The nurse should instruct the guardian to use hand gestures to promote understanding. D. The nurse should instruct the guardian to use facial expressions when speaking to assist in conveying the message being spoken.

A nurse is providing teaching to the guardian of a school-age child who has hearing loss. Which of the following techniques should the nurse recommend facilitate communication with the child? A. Exaggerate the pronunciation of each word B. Keep hands still when speaking c. Speak at the child's eye level D. Avoid using facial expressions when speaking

Correct Answer: B. "Adolescents need more sleep due to rapid growth." ** The nurse should identify that sleeping 10 hours on weekend nights is an expected finding in adolescents, who need more sleep time than other age groups. Common reasons for the increased need for sleep include stress, busy schedules (e.g. extracurricular activities), and rapid physical growth. Incorrect Answers: A. This finding does not indicate a need to check for anemia. C. This finding does not indicate a need to go to sleep earlier. D. This finding does not indicate a nutritional deficiency.

A nurse is providing teaching to the guardian of an adolescent. The guardian reports that the adolescent sleeps about 10 hr on weekend nights. Which of the following responses should the nurse provide? A. "Your child should have a blood test to check for anemia." B. "Adolescents need more sleep due to rapid growth." c. "Your child should not be staying up so late at night." D. "If your child eats properly, this should not happen."

Correct Answer: D. Allow the infant to splash in the bathtub ** The nurse should suggest allowing this 4-month-old infant to splash in the bathtub as a play activity. Splashing is appropriate for the developmental age of the infant and provides tactile stimulation. However, the nurse should emphasize and teach bath safety to prevent injury. Incorrect Answers: A. The nurse should suggest showing a board book with large pictures as a play activity to provide visual stimulation for a 9- to 12-month-old infant. An example of an activity that provides visual stimulation for a 4-month-old infant would be placing a toy that has bright colors in the infant's hand. B. The nurse should suggest imitating animal sounds as a play activity to provide auditory stimulation for a 9- to 12-month-old infant. activity that provides auditory stimulation for a 4-month-old infant is placing rattle in the infant's hand.

A nurse is providing teaching to the guardians of a 4-month-old infant on how to play with the infant. Which of the following play activities should the nurse suggest for this infant? A. Show the infant a board book with large pictures B. Imitate the sounds of different farm animals for the infant C. Give the infant a large push-pull toy D. Allow the infant to splash in the bathtub

Correct Answer: A. Add fortified rice cereal to the infant's formula ** The nurse should inform the guardians that adding fortified rice cereal or vegetable oil to the infant's formula helps promote weight gain. Incorrect Answers: B. The nurse should inform the guardians that caregiver consistency is recommended when providing feedings for the infant who has FTT. This consistency promotes the development of trust and attachment. C. The nurse should recommend restricting the infant's intake of juice until adequate weight is gained through prescribed sources of formula. D. The nurse should inform the guardians of the need to maintain a schedule for feeding times to promote weight gain and behavior modification.

A nurse is providing teaching to the guardians of an infant who has failure to thrive (FTT). Which of the following pieces of information should the nurse include in the teaching? A. Add fortified rice cereal to the infant's formula B. Alternate feedings between several family members C. Offer the infant juice between feedings D. Provide feedings on demand rather than on a schedule

Correct Answer: A. "My child should consume 1,000 calories per day." ** Toddlers who are 2 years old should consume 1,000 calories daily. Incorrect Answers: B. Toddlers who are 2 years old should have 2 oz of protein daily. C. Toddlers who are 2 years old should have no more than 24 oz (3 cups) of milk per day. D. Toddlers who are 2 years old should consume 8 oz (1 cup) of vegetables per day.

A nurse is providing teaching to the parent of a 2-year-old toddler about nutrition. Which of the following statements by the parent indicates an understanding of the teaching? A. "My child should consume 1,000 calories per day." B. "My child should have 4 oz of protein per day." c. "I should give my child 32 oz (4 cups) of milk per day." D. "I should feed my child 4 oz (1/2 cup) of vegetables per day."

Correct Answer: D. "I should give this medication to my child half an hour before breakfast." ** The parent should administer the medication to the child on an empty stomach. Incorrect Answers: A. Methylphenidate is a stimulant medication that can cause anorexia and weight loss. The parent should weigh the child 2 to 3 times per week to monitor for weight loss. B. Methylphenidate is a stimulant medication that can cause tachycardia and hypertension. C. Sustained-release tablets should not be crushed, chewed, or broken. The child should swallow the tablet whole.

A nurse is providing teaching to the parent of a child who has ADHD and a new prescription for methylphenidate sustained-release tablets. Which of the following statements by the parent indicates an understanding of the teaching? A. "I should expect my child to gain weight while taking this medication." B. "I should expect this medication to decrease my child's heart rate." C. "I should crush the medication and put it in my child's food." D. "I should give this medication to my child half an hour before breakfast."

Correct Answer: C. Notify the provider immediately if the sclera becomes inflamed ** Although the conjunctiva becomes inflamed during this infection, the sclera should remain clear and white. If the sclera becomes inflamed, it can indicate the presence of a serious conjunctival infection, and the child should be assessed immediately by an ophthalmologist. Incorrect Answers: A. The parent should clean secretions from the eye by wiping from the inner canthus towards the outer canthus and downward. B. Warm compresses can be applied to assist in removing dried secretions. However, the compress should not be left on the eye because can enhance bacterial growth. D. Applying pressure to the inner canthus of the eye after medication administration will block the lacrimal punctum. This will prevent the medication from flowing into the nasopharynx and causing an unpleasant taste.

A nurse is providing teaching to the parent of a toddler who has bacterial conjunctivitis. Which of the following instructions should the nurse include? A. Clean secretions from the infected eye by wiping from the outer canthus toward the inner canthus and upward B. Keep the infected eye covered with warm compresses for the first 24 to 48 hr C. Notify the provider immediately if the sclera becomes inflamed D. Apply pressure to the outer canthus of the eye for1 min after administering the eye drops

Correct Answer: C. "The tubes should stay in place until they fall out on their own." ** Tympanostomy tubes allow drainage from and ventilation to the middle ear. They usually fall out on their own within 6 to 12 months after insertion. Incorrect Answers: A. Most children do not need tympanostomy tubes for more than 1 year. B. With tympanostomy tubes in place, the child should wear earplugs whenever there is a possibility of getting contaminated or soapy water inside her ears. D. Hearing impairment is common with recurrent otitis media and can continue after tympanostomy tubes are in place.

A nurse is providing teaching to the parent of a toddler who is undergoing insertion of tympanostomy tubes. Which of the following statements should the nurse include? A. "The doctor will replace the tubes routinely about every 2 years." B. "If your child gets water in her ears will not cause any further problems." C. "The tubes should stay in place until they fall out on their own." D. "Now that the tubes are in place, she should not have any further problems with hearing."

Correct Answer: A. "I will apply the harness over a t-shirt and knee socks." ** Applying the harness over a t-shirt and knee socks indicates that the parent understands the instructions. This step will prevent the harness straps from rubbing against and causing irritation to the infant's skin. Incorrect Answers: B. Putting the infant's diaper over the harness will cause soiling of the harness and allow direct contact of the harness with the skin, which can lead to skin irritation and breakdown. C. The parent should return to the clinic for harness adjustments. Parents should not make any adjustments to the harness without the supervision of a health care professional. D. Lotions and powders should not be applied due to the possibility of causing irritation to the skin around the buckles.

A nurse is providing teaching to the parent of an infant who has developmental hip dysplasia and a new prescription for a Pavlik harness. Which of the following parent statements indicates an understanding of the teaching? A. "I will apply the harness over a t-shirt and knee socks." B. "I will put my baby's diaper over the harness." C. "I will make the required harness adjustments as my baby grows." D. "I will apply powder around the harness buckles each day."

Correct Answer: A. Withhold the medication if the infant's heart rate is less than 110/min ** The parent should withhold the medication and notify the provider if the infant's heart rate is less than 110/min. Incorrect Answers: B. The parent should not mix the medication with any liquids, including formula. C. The parent should notify the provider if the infant vomits frequently because this can be a manifestation of medication toxicity. D. The parent should not double the dose of medication for any reason because this could cause toxicity.

A nurse is providing teaching to the parent of an infant who has heart failure and a new prescription for digoxin elixir. Which of the following pieces of information should the nurse include? A. Withhold the medication if the infant's heart rate is less than 110/min B. Mix the medication in 120 mL (4 oz) of infant formula C. Expect the infant to vomit frequently while taking this medication D. Double the dose if the infant has increased edema

Correct Answer: A. Copying a circle ** The nurse should explain that copying a circle is a skill achieved by the age of 4 years. Incorrect Answers: B. Cutting food using a table knife is a fine motor skill expected of 7-year-old children. C. The initial use of cursive writing is an expected skill for an 8- to 9-year-old child. D. Children will print their first name around the age of 5 years.

A nurse is providing teaching to the parents of a 4-year-old child about fine motor development. Which of the following tasks should the nurse include as expected finding for this age group? A. Copying a circle B. Cutting foods using a table knife C. Beginning to write in cursive D. Printing the first and last name clearly

Correct Answer: A. Patch the unaffected eye ** Amblyopia is a disorder of the eye in which unilateral central blindness occurs as a result of another problem such as strabismus. With strabismus, muscle weakness allows an eye to wander so that the child cannot focus on an object with both eyes at the same time. This confusion causes the brain to ignore the signals from the weak eye in favor of the strong eye. This will result in central blindness if the child does not receive treatment by 6 years of age. To strengthen the weak eye muscles, the parents should patch the unaffected eye. Incorrect Answers: B. Providers instill mydriatic eye drops for ophthalmic examinations, not for strabismus. C. Prescription glasses will not help prevent amblyopia. D. Amblyopia is not an allergic disorder; therefore, antihistamines will have no therapeutic effect.

A nurse is providing teaching to the parents of a child who has strabismus. Which of the following instructions should the nurse include to prevent development of amblyopia? A. Patch the unaffected eye B. Administer mydriatic eye drops daily C. Obtain prescription eyeglasses D. Administer antihistamines

Correct Answer: A. "I will make sure my child drinks 240 mL (8 oz) of milk as soon as possible." ** Giving the child 10 to 15 g of simple carbohydrates such as 240 mL (8 oz) of milk will elevate the blood glucose level and alleviate hypoglycemia. Incorrect Answers: B. Administering additional insulin could worsen the child's hypoglycemia and lead to neurological effects such as seizures, shock, and coma. C. Rest is important for overall health; however, rest will not alleviate the child's symptoms. D. Checking the child's urine for glucose will not manage a hypoglycemic episode. Children who are hyperglycemic have glucose in their urine.

A nurse is providing teaching to the parents of a school-aged child who has type 1 diabetes mellitus about managing hypoglycemia. Which of the following responses by a parent indicates an understanding of the teaching? A. "I will make sure my child drinks 240 mL (8 oz) of milk as soon as possible." B. "I will give my child 2 units of regular insulin." C. "I will insist that my child lie down to rest for 30 min." D. "I will check my child's urine for glucose twice daily."

Correct Answer: D. Metabolic acidosis ** Metabolic acidosis is an expected finding for clients who have acute renal failure. Incorrect Answers: A. Hyperkalemia is an expected finding for clients who have acute renal failure. B. Hypocalcemia is an expected finding for clients who have acute renal failure. C. An elevated plasma creatinine level is an expected finding for clients who have acute renal failure.

A nurse is reviewing laboratory findings of an adolescent who has acute renal failure. Which of the following findings should the nurse expect? A. Hypokalemia B. Hypercalcemia C. Decreased plasma creatinine level D. Metabolic acidosis

Correct Answer: B. "Your baby can start the pneumococcal vaccine now." ** The infant can receive the first dose of the pneumococcal vaccine now, with 2 additional doses at 4 months and 12 months of age. Incorrect Answers: A. The nurse should instruct the guardian that the infant should not receive the varicella vaccine until 1 year of age. C. The nurse should instruct the guardian that the infant can receive an annual influenza vaccine beginning at 6 months of age. D. The nurse should instruct the guardian that the infant can receive the first dose of the measles, mumps, and rubella vaccine beginning at 12 months of age.

A nurse is reviewing recommended immunizations with the guardian of a 2-month-old infant. Which of the following statements should the nurse make? A. "Your baby can receive the varicella vaccine at 6 months of age." B. "Your baby can start the pneumococcal vaccine now." C. "Your baby should receive the flu vaccine before 6 months of age." D. "You baby can start the measles, mumps, and rubella vaccine now."

Correct Answer: B. Potassium 2.5 mEg/L ** A potassium level of 2.5 mEg/L indicates hypokalemia, which can cause arrhythmias or even cardiac arrest; therefore, the nurse should report this finding to the provider. Incorrect Answers: A. C. D. These values are within the expected reference range; therefore, the nurse should not report this finding to the provider.

A nurse is reviewing the laboratory report of a 2-year-old child who has diarrhea and has been vomiting for 24 hr. Which of the following findings should the nurse report to the provider? A. Hct 40% B. Potassium 2.5 mEg/L C. Serum creatinine 0.4 mg/dL D. BUN 6 mg/dL

Correct Answer: B. Hgb 6 g/dL ** This hemoglobin level is below the expected reference range and is indicative of anemia; therefore, the nurse should report this finding to the provider. Incorrect Answers: A. C. D. These values are within the expected reference range; therefore, the nurse should not report them to the provider.

A nurse is reviewing the laboratory report of a toddler who is receiving chemotherapy for leukemia. Which of the following laboratory values should the nurse report to the provider? A. Platelets 150,000/mm^3 B. Hgb 6 g/dL C. WBC 6,000/mm^3 D. Potassium 4.5 mEg/L

Correct Answer: C. WBC count 3,000/mm^3 ** The nurse should understand that the use of corticosteroids suppresses the child's immune system and increases the risk of infection. The nurse should identify that a WBC count of 3,000/mm^3 is below the expected reference range for a child and should report this finding to the provider. Incorrect Answers: A. The nurse should identify that a serum sodium level of 142 mEq/Lis within the expected reference range for a child. Therefore, it is not necessary for the nurse to report this finding to the provider. B. The nurse should identify that a serum potassium of 4 mEg/L is within the expected reference range for a child. Therefore, it is not necessary for the nurse to report this finding to the provider. D. The nurse should identify that a platelet count of 2980,000/mm^3 is within the expected reference range for a child. Therefore, it is not

A nurse is reviewing the laboratory reports of a child with acute nephrotic syndrome who has been receiving prednisone by mouth for the past week. Which of the following findings should the nurse report to the provider? A. Serum sodium 142 mEg/L B. Serum potassium 4 mEg/L C. WBC count 3,000/mm^3 D. Platelet count 298,000/mm^3

Correct Answer: B. 1.035 ** 1.035 is a concentrated specific gravity, which is an expected value for a child who is dehydrated; therefore, this is an expected urine specific gravity for a child who has experienced diarrhea for 24 hours. Incorrect Answers: A. 1.010 is within the expected reference range for urine specific gravity. C. 1.020 is within the expected reference range for urine specific gravity. D. 1.005 is decreased urine specific gravity, which could indicate excessive fluid intake rather than dehydration.

A nurse is reviewing the laboratory results of a child who has experienced diarrhea for the past 24 hr. Which of the following values for urine specific gravity should the nurse expect? A. 1.010 B. 1.035 C. 1.020 D. 1.005

Correct Answer: C. Sodium 125 mEq/L ** The nurse should expect an infant with acute renal failure to have hyponatremia. A sodium level of 125 mEg/L is below the expected reference range for an infant. Incorrect Answers: A. The nurse should expect an infant with acute renal failure to have an elevated BUN level. A BUN level of 5 mg/dL is within the expected reference range for an infant. B. The nurse should expect an infant with acute renal failure to have an elevated creatinine level. A creatinine level of 0.2 mg/dL is within the expected reference range for an infant. D. The nurse should expect an infant with acute renal failure to have hyperkalemia. A potassium level of 4.2 mEq/L is within the expected reference range for an infant.

A nurse is reviewing the laboratory values for a 6-month-old infant who has acute renal failure. Which of the following findings should the nurse expect? A. BUN 5 mg/dL B. Creatinine 0.2 mg/dL C. Sodium 125 mEq/L D. Potassium 4.2 mEg/L

Correct Answer: A. "The infant might be dehydrated." ** An increased hematocrit level indicates dehydration. Hematocrit levels rise when blood volume is decreased during dehydration. Incorrect Answers: B. This infant's hemoglobin value is within the expected reference range. Clients who have anemia have a decreased hemoglobin level. C. Overhydration would result in a decreased hematocrit level. A hematocrit level of 51% is an increased value. D. Leukemia presents with a high WBC count and a low RBC count. These hemoglobin and hematocrit levels do not indicate the impaired bone marrow production seen in leukemia.

A nurse is reviewing the medical record of a 2-month-old infant who has rotavirus. The nurse notes a hemoglobin level of 12 g/dL and a hematocrit of 51%. Which of the following statements by the nurse indicates an understanding of the laboratory values? A. "The infant might be dehydrated." B. "The infant might be anemic." C. "The infant might have received too much fluid." D. "The infant might have leukemia."

Correct Answer: D. Potassium 3.2 mEg/L ** The nurse should identify that a potassium level of 3.2 mEg/L is below the expected reference range of 4.1 to 5.3 mEg/L for an infant. Therefore, the nurse should report this finding to the provider. Incorrect Answers: A. The nurse should identify that a sodium level of 140 mEg/L is within the expected reference range of 134 to 150 mEg/L for an infant. B. The nurse should identify that a calcium level of 10.2 mg/dL is within the expected reference range of 8.8 to 10.8 mg/dL for an infant. C. The nurse should identify that a chloride level of 100 mEq/L is within the expected reference range of 90 to 110 mEq/L for an infant.

A nurse is reviewing the morning laboratory results of an infant who is receiving digoxin and furosemide for the treatment of heart failure. Which of following findings should the nurse report to the provider? A. Sodium 140 mEq/L B. Calcium 10.2 mg/dL c. Chloride 100 mEg/L D. Potassium 3.2 mEq/L

Correct Answer: B. Alcohol consumption ** Alcohol consumption is a maternal risk factor for the development of congenital heart disease. Incorrect Answers: A. Preeclampsia is not a maternal risk factor for the development of congenital heart disease. C. Placenta previa is not a maternal risk factor for the development of congenital heart disease. D. While late prenatal care is not optimal for prenatal care and outcomes, it is not a maternal risk factor for the development of congenital heart disease.

A nurse is reviewing the risk factors for the development of congenital heart disease with a client who is planning to conceive. Which of the following conditions should the nurse include as a maternal risk factor? A. Preeclampsia B. Alcohol consumption C. Placenta previa D. Late prenatal care

Correct Answer: B. The child had prenatal exposure to alcohol on a regular basis. ** Prenatal exposure to alcohol on a regular basis is a contributing factor to ADHD, along with prenatal nicotine exposure and exposure to lead or mercury. Incorrect Answers: A. The child's socioeconomic background is not likely to cause ADHD. Risk factors include prenatal alcohol exposure, lead exposure, genetic factors, and traumatic brain injury. C. Sibling activity level is not likely to cause ADHD. D. There is no indication that a current illness of the child's mother is a risk factor for ADHD.

A nurse is taking the history of and performing a physical on a school-age child who has attention deficit hyperactivity disorder (ADHD). Which of the following findings in the child's medical record should the nurse identify as a risk factor for ADHD? A. The child's family has a middle-class socioeconomic background. B. The child had prenatal exposure to alcohol on a regular basis. C. Both siblings of the child show moderate activity levels in school and play activities. D. The child's mother currently has diabetes mellitus.

Correct Answer: A. "Use a stable, relaxing routine like a bath and story time before bed." ** Routines are reassuring to preschoolers because they allow them to anticipate their environment and adapt appropriately. These actions help the child settle down prior to bedtime and allow parental-child interaction prior to bed. Incorrect Answers: B. Completely darkened rooms can elicit fear in preschoolers, including fear of the dark and of "monsters" that hide in the dark. C. Allowing the child to fall asleep routinely in a parent's lap might make him unable to fall asleep alone. The child should learn to sleep in his own bed with a transitional object, such as a blanket or toy. D. The parent should avoid responding to attention-seeking behavior, which the child learns will delay and disrupt bedtime.

A nurse is talking with a parent of a preschooler. The parent reports that she struggles to get her child to go to bed at a consistent time. She explains that the child gets out of bed, enters his parents' room, and cries when they tell him to stay in his own bed. Which of the following instructions should the nurse give the parent? A. "Use a stable, relaxing routine like a bath and story time before bed." B. "Make sure the room is completely dark when placing your child in bed." C. "Let your child go to sleep in your lap and then put him in his bed." D. "Respond consistently if your child cries out for you after putting him to bed."

Correct Answer: C. "My baby loves to play with the pillows in her crib." ** Parents should never place pillows in their infant's crib since they pose a suffocation hazard. Incorrect Answers: A. This comment indicates that the client has appropriate information about the fine motor development of 4-month-old infants. At this age, the infant is beginning to reach for and grasp objects and place them in her mouth. It is appropriate anticipatory guidance to start reminding older children at this time to keep small objects away from the infant's reach to keep her safe from a potential choking hazard. B. This comment indicates that the client has appropriate information about the gross motor development of 4-month-old infants. Parents should encourage infants to learn to explore their environment by crawling and rolling over. D. This comment indicates that the client has the appropriate information about using a car seat for a 4-month-old infant. Until the child is 2 years old, she should be in a rear-facing car seat in the back seat of the car.

A nurse is talking with the parent of a 4-month-old infant about growth and development. Which of the following statements indicates that the parent needs further teaching? A. "I need to remind my older kids to keep small objects out of the baby's reach." B. "I let my baby play on her stomach when she is awake and I am watching." C. "My baby loves to play with the pillows in her crib." D. "I put my baby in a rear-facing car seat in the back seat of the car."

Correct Answer: C. "Keep a diary of the foods your child eats each day." ** The nurse should encourage the parent to keep a diary of the foods the child eats throughout the day for 1 week. This can help the parent realize that the child may be eating better than expected. Evidence suggests that children can self-regulate their caloric intake. When they eat less at a meal, they can compensate by eating more at another meal or by having a snack. Incorrect Answers: A. The nurse should inform the parent that children's dietary habits can change from day to day. It is important to feed the child healthy foods and focus on the quality of food rather than the quantity of food during this time. B. The nurse should inform the client that calorie and fluid requirements decrease slightly in a preschool-aged child. The nurse should not promote an increase of calories and water in the child's diet. D. The nurse should inform the parent that excessive consumption of sweetened beverages, including fruit juices, can be associated with adverse health effects such as dental caries, obesity, and metabolic syndrome.

A nurse is talking with the parent of a preschool-aged child who tells the nurse, "My child has suddenly become disinterested in certain foods." Which of the following statements should the nurse make? A. "During this phase, feed your child anything that she will eat." B. "Increase the amount of calories and water your child consumes." C. "Keep a diary of the foods your child eats each day." D. "Provide a large variety of fruit juices for your child to choose from." Answer

Correct Answer: A. Regression ** The nurse should identify that the 6-year-old sibling's behavior is an indication of regression. With this defense mechanism, the individual reverts to a prior stage of development as a means of coping with stress. Incorrect Answers: B. Repression is a defense mechanism in which the individual involuntarily blocks awareness of a stressor. The 6-year-old sibling's behavior is not an indication of repression. C. Rationalization is a defense mechanism in which the individual attempts to explain unacceptable behavior or feelings with logical reasoning. The 6-year-old sibling's behavior is not an indication of rationalization. D. Identification is a defense mechanism in which individuals attempt to boost self-esteem by behaving like or portraying qualities of someone who is held in high regard. The 6-year-old sibling's behavior is not an indication of identification.

A nurse is talking with the parent of an infant during a well-child visit. The parent states, "My 6-year-old child started wetting the bed after we brought her sister home. She hasn't done that in over a year." This behavior by the sibling is an indication of which of the following defense mechanisms? A. Regression B. Repression C. Rationalization D. Identification

Correct Answer: D. Passive smoking ** The nurse should identify passive smoking as a risk factor for otitis media. Exposure to secondhand smoke promotes the attachment of pathogens to the middle ear, extends the inflammatory response, and impairs drainage through the Eustachian tube. Each of these effects increases the risk for development of otitis media. Incorrect Answers: A. The nurse should identify winter and spring months as risk factors for otitis media. Respiratory infections are common during these months, and otitis media commonly occurs after this type of infection. B. The nurse should identify bottle-feeding as a risk factor for otitis media. The slanted position of the infant during bottle-feeding increases the risk of formula entering into the Eustachian tube, which raises the risk for otitis media. C. The nurse should identify ages 6 years and younger as a risk factor for otitis media. Otitis media is most common during the first 2 to 3 years of life and at ages 4 to 6 years when the child starts going to school.

A nurse is teaching a group of parents and guardians about otitis media. Which of the following should the nurse identify as a risk factor for this illness? A. Summer months B. Breastfeeding C. Ages 7 to 10 years D. Passive smoking

Correct Answer: D. "Toddlers do not have well-developed abdominal muscles." ** The abdominal muscles are immature and minimally developed at this stage. Therefore, many toddlers have a "potbellied" appearance. Incorrect Answers: A. Constipation is not the cause of the toddler's protruding abdomen. B. Toddlers are not growing as rapidly as they did in infancy, and weight gain does not cause a protruding abdomen. C. A spinal deformity is not generally the cause of a toddler's protruding abdomen.

A nurse is teaching a group of parents of toddlers about growth and development. A parent asks, "Why does my child's abdomen stick out?" Which of the following replies should the nurse provide? A. "You should give your child a stool softener daily." B. "Toddlers gain weight at a rapid pace." C. "You should have your child assessed for a spinal deformity." D. "Toddlers do not have well-developed abdominal muscles."

Correct Answers: A. Hot dogs B. Grapes C. Bagels D. Marshmallows ** Foods that are shaped like a tube, such as hot dogs and grapes, place toddlers at risk for choking because they can completely block the throat when swallowed whole due to their shape and solidity. Foods that are hard to chew, such as bagels and marshmallows, place toddlers at risk for choking; if swallowed before they are adequately chewed, they can block the airway. Incorrect Answer: E. All foods and fluids can potentially cause choking. However, graham crackers become soft quickly when mixed with saliva. Their

A nurse is teaching a group of parents of toddlers about measures to reduce the risk of choking. Which of the following foods increase the risk of choking in toddlers? (Select all that apply.) A. Hot dogs B. Grapes C. Bagels D. Marshmallows E. Graham crackers Answer

Correct Answer: C. "I need to apply paste to the back of the wafer on my child's appliance." ** The parent should apply stoma paste to the back of the wafer on the appliance and around the stoma. This paste will act as a sealant to prevent skin breakdown. Incorrect Answers: A. The parent should dress the infant in 1-piece outfits to restrict the infant's hands from reaching the pouch. B. The parent should use diapers that are larger than the ones the child usually wears to go over the stoma and facilitate drainage. D. A child who has a colostomy will need bladder training when developmentally ready because the urinary system is still intact.

A nurse is teaching a parent of an infant who has a colostomy. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will not dress my child in 1-piece outfits." B. "I need to buy diapers that are tighter than those my infant usually wears." C. "I need to apply paste to the back of the wafer on my child's appliance." D. "I will not need to toilet train my child."

Correct Answer: D. Demonstrate the injection technique on an orange ** The nurse should apply the safety and risk-reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. Demonstrating the injection technique on an orange poses no risk to the client and is the first action the nurse should take. The nurse should use Maslow's hierarchy of needs, the ABC priority setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. Incorrect Answers: A. The nurse should allow the parent to give the nurse an injection while the child observes; however, there is another action the nurse should take first. B. The nurse should have the child teach the injection technique to the parents; however, there is another action the nurse should take first. C. The nurse should have the parent give the insulin injection to the child; however, there is another action the nurse should take first.

A nurse is teaching a school-age child and his parents how to self-administer insulin. Which of the following actions should the nurse take first? A. Allow a parent to administer an injection to the nurse B. Have the child teach the injection technique to the parents C. Have a parent administer the insulin injection to the child D. Demonstrate the injection technique on an orange

Correct Answer: C. "You can use a vial of insulin for up to 30 days." ** The child can use an opened vial of insulin for 28 to 30 days stored at room temperature or in the refrigerator. Incorrect Answers: A. Sugar-free cola will not increase the blood sugar because it does not contain sugar. Instead, the nurse should encourage the child to drink juice or milk and eat a complex carbohydrate. B. Insulin requirements increase during puberty due to a decreased sensitivity to insulin, resulting in an increase in the child's insulin dosage. D. Blood glucose levels rise during times of illness and stress; therefore, the child might need to contact the provider for an increased insulin dosage.

A nurse is teaching a school-age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements should the nurse make? A. "If you take too much insulin, drink a sugar-free cola." B. "You will need to decrease your insulin dosage when you become a teenager." C. "You can use a vial of insulin for up to 30 days." D. "Stop taking your insulin if you are vomiting."

Correct Answer: D. "I will place a pressure dressing over the area following the procedure." ** Applying a pressure dressing over the area following the procedure helps prevent bleeding from the site. Incorrect Answers: A. The child should not receive an antibiotic prior to a bone marrow biopsy because the use of an antibiotic might skew the test results. B. The child should be in the prone position because the provider will obtain the specimen from the iliac crest. C. Bone marrow aspiration will not affect the brain or its fluids. Lumbar punctures are likely to cause headaches.

A nurse is teaching a school-age child who is to undergo a bone marrow aspiration. Which of the following statements should the nurse make? A. "I will give you an antibiotic before your procedure." B. "I will place you on your side during the procedure." C. "You might have a headache following the procedure." D. "I will place a pressure dressing over the area following the procedure."

Shake the inhaler while holding it upright. Position the mouthpiece in the mouth. Slowly inhale the medication. Hold the breath for 5 to 10 sec.

A nurse is teaching a school-age child with asthma how to use a metered-dose inhaler. In which order should the nurse instruct the child to perform the following steps and evaluate return demonstration? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) Hold the breath for 5 to 10 sec. Shake the inhaler while holding it upright. Position the mouthpiece in the mouth. Slowly inhale the medication.

Correct Answer: C. Barking cough ** Infants who have tracheomalacia have a weakened trachea, which can lead to collapse. Clinical manifestations of tracheomalacia include a barking cough, stridor, wheezing, cyanosis, and apnea. Incorrect Answers: A. Tracheoesophageal fistula is an upper gastrointestinal disorder; therefore, bowel sounds would not be absent in this condition. B. Neck contortions are an expected finding in an infant who has a hiatal hernia. D. Projectile vomiting is an expected finding in an infant who has hypertrophic pyloric stenosis.

A nurse is teaching about clinical manifestations of tracheomalacia to the parent of an infant who had tracheoesophageal fistula repair as a newborn. Which of the following findings should the nurse include in the teaching? A. Absence of bowel sounds B. Neck contortions C. Barking cough D. Projectile vomiting

Correct Answer: B. "I will continue to take my medication when my peak flow rate is in the green zone." ** This statement by the adolescent indicates an understanding of the teaching. A peak flow rate in the green zone indicates the current treatment has been effective; therefore, the adolescent should continue with their current medication regimen. Incorrect Answers: A. The nurse should instruct the adolescent to use a quick-relief (i.e. rescue) medication when they feel short of breath because this is a manifestation of an acute attack. C. The nurse should instruct the adolescent to obtain 3 readings and to write down the highest of the 3 readings rather than the average. D. The nurse should inform the adolescent that a flow rate in the yellow zone indicates inadequate control of asthma.

A nurse is teaching an adolescent about managing asthma and using a peak expiratory flow meter. Which of the following statements by the client demonstrates an understanding of the teaching? A. "I will use my peak flow meter whenever I feel short of breath." B. "I will continue to take my medication when my peak flow rate is in the green zone." C. "I need to use the average of 3 readings when I measure my flow rate." D. "My asthma is being controlled if my flow rate is in the yellow zone."

Correct Answer: D. Repeat memorized facts about the painful event ** Having the adolescent repeat memorized facts about the painful event is an example of the nonpharmacological pain management strategy of thought-stopping. Thoughts such as "the pain will be gone soon" or "I'll be home by this time tomorrow" can help the adolescent control the pain. After listing the facts, the nurse should then have the adolescent condense and memorize the facts to repeat them whenever pain occurs. Incorrect Answers: A. Having the adolescent put together a puzzle is an example of the nonpharmacological pain management strategy of distraction. B. Having the adolescent discuss a recent pleasurable event is an example of the nonpharmacological pain management strategy of guided imagery. C. Having the adolescent tighten and then relax each body part is an example of the nonpharmacological pain management strategy of

A nurse is teaching an adolescent about various strategies for chronic pain management. Which of the following activities should the nurse use as an example of the nonpharmacological strategy of thought-stopping? A. Assemble a puzzle B. Discuss a recent pleasurable event C. Tighten and then relax each body part D. Repeat memorized facts about the painful event

Correct Answer: B. "You should drink 4 oz of orange juice if you experience hypoglycemia." ** The nurse should tell the client to drink 4 oz of orange juice if hypoglycemia occurs. Incorrect Answers: A. The nurse should tell the client to drink 6 oz of a regular soft drink if hypoglycemia occurs. C. The nurse should tell the client to take 4 glucose tablets if hypoglycemia occurs. D. The nurse should tell the client to take 2 tsp of sugar if hypoglycemia occurs.

A nurse is teaching an adolescent client who has type 1 diabetes mellitus about managing hypoglycemia. Which of the following statements should the nurse include in the teaching? A. "You should drink 8 oz of a regular soft drink if you experience hypoglycemia." B. "You should drink 4 oz of orange juice if you experience hypoglycemia." C. "You should take 2 glucose tablets if you experience hypoglycemia." D. "You should take 3 tsp of sugar if you experience hypoglycemia."

Correct Answer: D. "I will record the highest reading of three attempts." ** After establishing a personal best, the client should routinely check the PEFM by performing 3 attempts and recording the highest reading of the 3. Incorrect Answers: A. The nurse should instruct the adolescent to take a deep breath, place the lips around the mouthpiece, and then blow into the mouthpiece as hard and fast as possible. B. Values in the green zone represent 80% to 100% of the child's personal best; therefore, this does not warrant calling the provider. C. Slowly exhaling over a 10-second interval is an incorrect method of using the PEFM.

A nurse is teaching an adolescent who has asthma about how to use a peak expiratory flow meter (PEFM). Which of the following responses by the adolescent indicates an understanding of the teaching? A. "I will breathe in through the mouthpiece, hold my breath for 5 sec, and then exhale." B. "If I get a reading in the green zone, I will tell my parents immediately so they can call the doctor." C. "I will slowly exhale through the mouthpiece over a 10 sec interval." D. "I will record the highest reading of three attempts."

Correct Answer: B. "Hospice staff members consider the family's needs to be just as important as those of the child." ** The nurse should inform the family that part of the philosophy of hospice care is to provide care for the family's needs as well as those of the child. Assisting with respite care, counseling, spiritual needs, and care of the family following the child's death are all part of hospice care. Incorrect Answers: A. The nurse should inform the family that the hospice staff works closely with the family to coordinate the care of the child. Family members are active participants in the child's care and attend to the child's personal and hygiene needs as well as administration of medication. C. The nurse should inform the family that hospice care continues after the death of the child. Bereavement care is provided for a year or longer, if needed, to assist the family with adjusting to life following the loss of the child. D. The nurse should inform the family that hospice care focuses on palliative care and supporting the natural process of the child's death.

A nurse is teaching the family of a child about hospice care. Which of the following statements should the nurse include in the teaching? A. "The hospice staff will be the primary caregivers for the child." B. "Hospice staff members consider the family's needs to be just as important as those of the child." C. "Hospice care will end with the death of your child." D. "The priority of hospice care is to provide curative treatment for the child."

Correct Answer: C. "Have your child take responsibility for actions if he tries to blame the imaginary friend." ** The nurse should inform the guardian that imaginary playmates are common during the preschool years due to the high level of imagination among this age group. Although having an imaginary friend is considered healthy, the preschooler might try to use this imaginary friend as a means of avoiding responsibility or punishment for unacceptable behavior. The nurse should inform the guardian of the need to have the preschooler take responsibility for his actions. Incorrect Answers: A. Imaginary playmates are common during the preschool years due to the high level of imagination among this age group. B. Imaginary playmates are common during the preschool years and are not a cause for concern as long as the preschooler also socializes with other children. D. The nurse should instruct the guardian that this behavior is expected and that pretending with the preschooler is okay.

A nurse is teaching the guardian of a preschooler. The guardian states that the preschooler has had an imaginary playmate for about 3 months. Which of the following pieces of information should the nurse give the guardian? A. "Children commonly begin having imaginary friends when they reach school age." B. "Notify your provider if the imaginary friend persists longer than 6 months." C. "Have your child take responsibility for actions if he tries to blame the imaginary friend." D. "Set limits by not allowing your child to have the imaginary friend present during family meals."

Correct Answer: C. Deep, rapid respirations ** Deep and rapid respirations are known as Kussmaul respirations, which is a manifestation of DKA. This respiratory pattern is caused by the body's attempt to rid itself of the excess carbon dioxide that results from the presence of ketones. The child's breath can be sweet smelling due to the body's attempt to eliminate ketones through the respiratory system. Incorrect Answers: A. A rapid heart rate is a manifestation of DKA. B. Sunken eyeballs are a manifestation of DKA, resulting from dehydration. D. Decreased urinary output is a manifestation of hypoglycemia. Increased urinary output is a manifestation of hyperglycemia that can lead to DKA.

A nurse is teaching the guardian of a school-age child who has diabetes mellitus how to recognize diabetic ketoacidosis (DKA). Which of the following findings should the nurse identify as a manifestation of this complication? A. Slow heart rate B. Protruding eyeballs C. Deep, rapid respirations D. Decreased urinary output

Correct Answer: C. "Gently pull the ear cartilage down and back when administering the medication." ** The nurse should instruct the guardian to pull the pinna gently down and back to straighten the eustachian tube when administering the medication. Incorrect Answers: A. The nurse should instruct the guardian that the medication should be at room temperature or slightly warmer to prevent pain and vertigo during administration. B. The nurse should instruct the guardian to place the child prone or supine, with the head turned to the side to administer the drops. The child should remain in this position for 2 to 3 minutes following administration so the medication can fully enter the ear canal. D. The nurse should instruct the guardian to position the bottle so the ear drops fall against the side of the ear canal to avoid placing the drops directly onto the tympanic membrane.

A nurse is teaching the guardian of an 18-month-old toddler about otic medication administration. Which of the following statements should the nurse make? A. "Administer the drops immediately after removing the medication from the refrigerator." B. "Place the child in a seated position with the head tilted to the side for administration." C. "Gently pull the ear cartilage down and back when administering the medication." D. "Position the medication bottle so the drops do not touch the side of the ear canal."

Correct Answer: B. Orange juice ** The nurse should recommend that the guardians administer the iron supplement with orange juice or other citrus juices to increase the absorption of iron. Incorrect Answers: A. The nurse should inform the guardians that protein does not increase the absorption of iron; eggs, a source of protein, can decrease iron absorption. C. The nurse should inform the guardians that iron should not be administered with milk because milk decreases iron absorption. D. The nurse should inform the guardians that iron should not be administered with fiber; oatmeal, a source of whole-grain fiber, can decrease iron absorption.

A nurse is teaching the guardians of a toddler who has a new prescription for an oral iron supplement. To increase the child's absorption of the iron, the should recommend administering the supplement with which of the following? A. Eggs B. Orange C. Milk D. Oatmeal

Correct Answer: C. "Thicken feedings with rice cereal." ** The nurse should instruct the guardians about the correct way to thicken feedings with rice cereal. Thickened feedings with rice cereal decrease the infant's manifestations of GER and promote weight gain if needed. Incorrect Answers: A. The nurse should instruct the guardians to keep clothing and diapers loose around the infant's abdomen to decrease pressure on the stomach. Increased abdominal pressure increases the manifestations of GER. B. The nurse should inform the guardians that nasogastric feedings are indicated if GER becomes severe and the infant exhibits manifestations of failure to thrive. D. The nurse should instruct the guardians to hold the infant upright for at least 30 minutes after each feeding. This upright position helps decrease the infant's manifestations of GER.

A nurse is teaching the guardians of an infant who has mild gastroesophageal reflux (GER). Which of the following instructions about feeding therapies should the nurse recommend? A. "Apply the infant's diaper snugly prior to feedings." B. "Administer nasogastric feedings." C. "Thicken feedings with rice cereal." D. "Place the infant in a lateral position for 1 hour after feedings."

Correct Answer: D. "My infant drinks at least 2 gt of skim milk each day." ** As the infant transitions into toddlerhood, whole milk intake should average 24 to 30 oz per day. Too much milk can affect the child's intake of solid foods and result in iron deficiency anemia. Skim milk is not recommended until after age 2 since it lacks essential fatty acids, which are needed for growth and development. Incorrect Answers: A. Children should not exceed 4 to 6 oz of juice per day between the ages of 1 and 6 years. Infants who are under 4 to 6 months of age should not be given juice. B. At 12 months of age, infants should be offered finger foods. Finger foods stimulate the pincer grasp, which aids fine motor development. Cereal is small but dissolves in the infant's saliva and would not cause an airway obstruction. Chilled banana slices are an appropriate food choice and help relieve teething. C. Introducing infants to foods prepared for the rest of the family is appropriate and helps them feel included. Home-cooked foods alsoprovide infants with the nutrients they need. At 12 months of age, infants are able to eat soft table foods such as mashed potatoes, green beans, bread, and finely chopped meat.

A nurse is teaching the parent of a 12-month-old infant about nutrition. Which of the following statements by the parent indicates a need for further teaching? A. "I can give my baby 4 oz of juice to drink each day." B. "I will offer my baby dry cereal and chilled banana slices as snacks." C. "I am introducing my baby to the same foods the family eats." D. "My infant drinks at least 2 qt of skim milk each day."

Correct Answer: D. "Weigh your child twice per week while he is taking this medication." ** The nurse should instruct the parent to weigh the child 2 to 3 times per week to monitor for weight loss, which is an adverse effect of methylphenidate. The parent should report weight loss to the provider. Incorrect Answers: A. The nurse should instruct the parent that sustained-release tablets must be swallowed whole and not crushed, split, or chewed. B. The nurse should instruct the parent to administer the medication 30 minutes before breakfast on an empty stomach. The nurse should instruct the parent to administer the medication no later than 1800 to avoid insomnia, which is an adverse effect of methylphenidate. C. The nurse should identify that methylphenidate does not cause cloudy urine. Common adverse effects of methylphenidate include insomnia, weight loss, anorexia, and tachycardia.

A nurse is teaching the parent of a child who has ADHD and a new prescription for methylphenidate sustained-release tablets. Which of the following pieces of information should the nurse include in the teaching? A. "Crush the medication and mix it in your child's food." B. "Administer the medication 1 hour before bedtime." C. "Expect your child to have cloudy urine while he is taking this medication." D. "Weigh your child twice per week while he is taking this medication."

Correct Answer: B. "I'll check his blood glucose more often." ** The parent should check the child's blood glucose every 3 hours during an illness because the level tends to rise even if the child eats less food. Incorrect Answers: A. Children often report decreased appetite even with a minor respiratory ailment. Unless the child is nauseated or actively vomiting, the parent should encourage the usual food intake. Substituting food the child can digest easily can help prevent dehydration and promote recovery. C. The parent should encourage increased fluid intake to promote excretion of ketones and prevent dehydration. D. Unless the provider prescribes a change, the parent should adhere to child's usual regimen of long-acting insulin with adjustments in short-acting insulin according to blood glucose levels.

A nurse is teaching the parent of a child who has type l diabetes mellitus how to manage the child's disorder during an illness such as a cold. Which of the following statements by the parent indicates an understanding of the teaching? A. "I'll reduce my child's food intake." B. "I'll check his blood glucose more often." C. "I'll limit his fluid intake between meals." D. "I won't administer his long-acting insulin dose."

Correct Answer: A. "I will give my child a dose of albendazole today and again in 2 weeks." ** The nurse should instruct the parent to repeat the dose of albendazole in 2 weeks to eradicate the parasite and prevent reinfection. Incorrect Answers: B. Pinworm specimens are collected in the morning as soon as the child wakes up and before the child bathes or has a bowel movement. C. To prevent reinfection, the child should be given a shower rather than a tub bath. D. The child's bed linens and clothing should be washed in hot water because pinworms can survive on surfaces for an extended period of time.

A nurse is teaching the parent of a preschool-aged child about the treatment for pinworms. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will give my child a dose of albendazole today and again in 2 weeks." B. "I will collect specimens immediately after my child has a bowel movement." C. "I will give my child a tub bath twice each day." D. "I will place my child's bed linens in a sealed plastic bag for 7 days."

Correct Answer: A. Corn tortilla with black beans ** Children who have celiac disease are placed on a gluten-free diet. Gluten is found in wheat, rye, and barley. Selecting products made from corn indicates an understanding of the teaching, as corn and beans are gluten-free foods. Incorrect Answers: B. Pizza often contains gluten. Gluten is found in wheat, rye, and barley and should be avoided by a child who has celiac disease. C. Prepared soups often contain gluten. D. Hot dogs and hot dog buns often contain gluten.

A nurse is teaching the parent of a school-age child who has celiac disease. Which of the following foods selected by the parent indicates an understanding the teaching? A. Corn tortilla with black beans B. Pizza C. Canned soup D. Hot dogs

Correct Answer: A. "I will lock my medications in the medicine cabinet." ** Locking up medications and other potential poisons prevents access. Toddlers have improved gross and fine motor skills that allow further exploration of the environment and possible access to hazardous substances. Incorrect Answers: B. The parent should keep the child's crib mattress at the lowest level to prevent the child from climbing or falling from the crib. C. The parent should turn pot handles to the back of the stove while cooking to prevent the toddler from pulling the hot item and receiving burns. D. Syrup of ipecac is not recommended for the treatment of poisoning at home. Caustic substances can cause more damage when vomiting is induced.

A nurse is teaching the parent of a toddler about home safety. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will lock my medications in the medicine cabinet." B. "I will keep my child's crib mattress at the highest level." c. "I will turn pot handles to the side of my stove while cooking." D. "I will give my child syrup of ipecac if she swallows something poisonous."

Correct Answer: A. Cow's milk ** According to evidence-based practice, cow's milk is the most common food allergy in children. Some children are sensitive to the protein casein found in cow's milk. They have difficulty metabolizing casein and are, therefore, allergic to cow's milk. Incorrect Answers: B. Some children have an allergy or sensitivity to wheat; however, evidence-based practice indicates that another food allergy is more common. C. Some children have an allergy or sensitivity to corn syrup, especially among children who have eczema; however, evidence-based practice indicates that another food allergy is more common. D. Eggs contain albumin, which is a protein that some clients are unable to metabolize; however, evidence-based practice indicates that another food allergy is more common.

A nurse is teaching the parent of an infant about food allergens. Which of the following is the most common food allergy in children? A. Cow's milk B. Wheat bread C. Corn syrup D. Eggs

Correct Answers: C. Position the car seat so it is rear-facing. D. Secure a safety gate at the top and bottom of the stairs. E. Maintain the water heater temperature at 49°C (120°F). ** Infants and children should remain in the rear-facing position in a car seat until the age of 2 years or until they reach the recommended height and weight per the manufacturer's guidelines. As the infant begins to crawl and becomes more mobile, the risk of falls increases. To prevent a burn injury, the temperature of the water heater should not exceed 49°C (120°F). Incorrect Answers: A. A stationary infant walker is recommended. Wheeled infant walkers can quickly move across uneven surfaces and result in injury. B. Soft pillows and cushions should not be used in cribs due to the increased risk of suffocation.

A nurse is teaching the parent of an infant about home safety. Which of the following pieces of information should the nurse include? (Select all that apply.) A. Use a wheeled infant walker. B. Place soft pillows around the edge of the infant's crib. C. Position the car seat so it is rear-facing. D. Secure a safety gate at the top and bottom of the stairs. E. Maintain the water heater temperature at 49°C (120 F).

Correct Answer: C. "I should make sure my baby's clothing does not have buttons." ** The nurse should instruct the parent to avoid clothing with buttons to reduce the risk of choking and aspiration. Incorrect Answers: A. The nurse should instruct the parent to avoid the use of talcum powder to reduce the risk of aspiration pneumonia if inhaled. B. The nurse should instruct the parent to avoid using a drop-side crib to reduce the risk of suffocation and falls. D. The nurse should instruct the parent to use a crib that has slats that are <6 cm (2.36 in) apart to reduce the risk of suffocation.

A nurse is teaching the parent of an infant about injury prevention. Which of the following statements by the parent indicates an understanding of the teaching? A. "I should lightly shake talcum powder on my baby's skin after each diaper change." B. "I should use a drop-side crib after my baby is 6 months old." C. "I should make sure my baby's clothing does not have buttons." D. "I should ensure the crib slats are no more than 3 inches apart."

Correct Answer: B. "We should not smoke around our child." ** Preventing exposure to tobacco smoke at home can prevent further episodes of ear infections because tobacco smoke can cause inflammation of the respiratory tract. Incorrect Answers: A. A child who has an ear infection is not contagious; therefore, the child may play with other children who have ear infections. C.A child who has recurrent ear infections is able to swim; however, wearing earplugs may decrease the risk of infection. D. A child who has recurrent ear infections should not forcefully blow the nose during a cold, as this causes organisms to ascend through the eustachian tubes.

A nurse is teaching the parents of a 3-year-old child who has persistent otitis media about prevention. Which of the following statements by the parents indicates an understanding of the teaching? A. "My child should not play around others who have ear infections." B. "We should not smoke around our child." C. "My child should not swim this summer." D. "I will encourage my child to blow his nose forcefully when he has a cold."

Correct Answer: A. "I will add 1 teaspoon of rice cereal per ounce to my baby's formula." ** The parents can give the infant thickened feedings with rice cereal to help decrease reflux. The added calories also can help infants who are underweight due to gastroesophageal reflux. Incorrect Answers: B. The American Academy of Pediatrics recommends supine sleeping for infants. Infants who have gastroesophageal reflux should be placed in a supine position with the head elevated. C. Decreasing the number of feedings per day is contraindicated. An infant must eat to gain nutrients, and caloric intake important for growth and development. D. Loperamide is an antidiarrheal medication that is contraindicated for children under 2 years of age. An infant who has gastroesophageal reflux can benefit from an H2 receptor antagonist or proton pump inhibitor.

A nurse is teaching the parents of a 4-month-old infant who has gastroesophageal reflux. Which of the following statements by a parent indicates an understanding of the teaching? A. "I will add 1 teaspoon of rice cereal per ounce to my baby's formula." B. "I will place my baby on her side when sleeping." c. "I will decrease the number of feedings my baby receives per day." D. "I will give my baby loperamide with each feeding."

Correct Answer: C. "Your child will need a botulinum toxin ** A injection to reduce muscle spasticity." Children who have cerebral palsy have spasticity in their muscles. The child can receive botulinum toxin type A injections into affected muscles, which reduce spasticity. Incorrect Answers: A. Children who have cerebral palsy may eat food by mouth; however, the parents might need to use special feeding techniques. B. Children who have cerebral palsy are able to participate in recreational activities. Some facilities have specific activities for those children with disabilities. D. The parents should not use throw rugs because children who have cerebral palsy have an increased risk of falls.

A nurse is teaching the parents of a child who has cerebral palsy. Which of the following statements should the nurse make? A. "Your child will be unable to eat by mouth." B. "Your child will be unable to participate in recreational activities." C. "Your child will need a botulinum toxin A injection to reduce muscle spasticity." D. "Your child will need throw rugs placed over non-carpeted areas."

Correct Answer: A. "My child may take aspirin for his joint pain." ** Children who have rheumatic fever may take salicylates (aspirin) to control the inflammatory process that occurs in the joints. Incorrect Answers: B. A child who has rheumatic fever does not require blood transfusions since there is no blood loss from this disorder. C. A child who has rheumatic fever only needs standard isolation precautions. Rheumatic fever is an immune response that occurs after an infection with group A B- hemolytic streptococci. D. Kawasaki disease causes peeling hands, but rheumatic fever does not.

A nurse is teaching the parents of a child who has rheumatic fever. Which of the following statements by a parent indicates an understanding of the teaching? A. "My child may take aspirin for his joint pain." B. "My child will need a blood transfusion prior to discharge." C. "I will need to wear a gown when I'm in my child's room." D. "I will apply lotion to my child's peeling hands."

Correct Answer: D. "You will need to increase the dosage as your child gains weight." ** Epinephrine is a weight-based medication that is available in dosages of 0.15 mg and 0.3 mg. As the child grows, it will be necessary to change the epinephrine dosage that is administered. Incorrect Answers: A. Injectable epinephrine is an intramuscular injection administered into the vastus lateralis muscle of the child's thigh. B. Oral immunotherapy might be attempted na child who has had an anaphylactic reaction to a food product. This therapy involves the administration of minute amounts of the allergen to increase tolerance to the food. However, this is only done under medical supervision. The parents should avoid administering peanut products to the child and should only use the epinephrine when an allergic reaction occurs. C. The nurse should instruct the parents to notify emergency services following the administration of epinephrine because the child might experience a delayed reaction even if the epinephrine has been administered. This delayed reaction can result in respiratory or cardiac arrest.

A nurse is teaching the parents of a toddler who had an anaphylactic reaction to peanut butter about administering injectable epinephrine. Which of the following instructions should the nurse include? A. "Common sites for an injection of epinephrine are the fatty tissue found in the upper arm and in the lower abdomen." B. "Administer epinephrine prior to giving your child peanut products in the future." C. "No further treatment is needed after injecting the epinephrine." D. "You will need to increase the dosage as your child gains weight."

Correct Answer: B. "You should keep your child's fingernails trimmed short." ** The nurse should instruct the parents to keep their child's fingernails trimmed short to minimize the collection of ova under the nails. Incorrect Answers: A. The parents should encourage the toddler to take a shower instead of a tub bath. C. The parents should dress the child in a 1-piece sleeping outfit. D. Recurrence is common, and the disease should be managed and treated as it was previously.

A nurse is teaching the parents of a toddler who has enterobiasis about managing this parasitic disease. Which of the following pieces of information the nurse include in the teaching? A. "You should encourage your child to take a tub bath daily." B. "You should keep your child's fingernails trimmed short." C. "You should dress your child in a 2-piece outfit at bedtime." D. "You should expect your child not to have a recurrence of the parasitic disease."

Correct Answer: D. "Your child will need to take thyroid hormone replacement for her entire life." ** In congenital hypothyroidism, the child does not manufacture an adequate amount of thyroid hormone to maintain the appropriate metabolic rate. The child will require lifelong thyroid hormone replacement to support normal growth and development. Incorrect Answers: A. A child who has congenital hypothyroidism does not require estrogen replacement. B. A child who has congenital hypothyroidism does not have a blood coagulation disorder. C.A child who has congenital hypothyroidism has a thyroid gland that is absent, small, or malfunctioning; however, the child does not require surgical removal of the gland.

A nurse is teaching the parents of an infant who has congenital hypothyroidism. Which of the following directions should the nurse provide? A. "Your child will need to take estrogen daily when she reaches puberty." B. "Your child will need monthly blood coagulation studies." C. "Your child will need surgery to remove the diseased thyroid." D. "Your child will need to take thyroid hormone replacement for her entire life."

Correct Answer: D. "My child spends 4 hours per day using online chat rooms." ** Adolescents may spend time using a computer, but parents should know what they are doing and who they are communicating with and limit the time. The American Academy of Pediatrics guidelines recommends 2 hours of screen time daily. Incorrect Answers: A. Adolescents strive for independence and have frequent mood changes. B. Many adolescents assert their independence by controlling what they can. Their environment is an area where they feel they can assert control. C. Adolescents are very preoccupied with body image and how they appear to others. Therefore, they may shower more than once daily to maintain their self-appearance.

A nurse is teaching to a group of parents of adolescents about developmental needs. Which of the following statements by a parent should the investigate further? A. "My child has frequent mood swings." B. "My child has a very messy bedroom." c. "My child takes 1 to 2 showers per day." D. "My child spends 4 hours per day using online chat rooms."

Correct Answer: B. "Tell me about your favorite video game." ** The nurse should use the therapeutic communication technique of exploring to encourage the child to respond with more than just the name of the game. This type of communication fosters a rapport and encourages communication. Incorrect Answers: A. The nurse should avoid the use of closed-ended questions when attempting to foster a rapport. This type of question typically results in a yes or no answer and does not encourage further communication. C. The nurse should avoid nontherapeutic statements that shift the focus away from the client and do not show interest in him as an individual. D. The nurse should avoid the use of closed-ended questions when attempting to foster rapport. This type of question typically results in a yes or no answer and does not encourage further communication.

A nurse on a pediatric mental health unit is caring for a school-age child. Which of the following questions or statements should the nurse provide to rapport and encourage conversation? A. "Do you like school?" B. "Tell me about your favorite video game." C. "We have another child your age on the unit." D. "Would you like your friends to visit you?"

Correct Answer: C. "Would you like assistance in planning where your child will die?" ** The nurse should inform the parents that they can choose to keep the child in a hospital setting or take the child home to die. The nurse should be aware that active participation in planning for the location of the child's death promotes positive bereavement outcomes. The nurse should provide assistance to the parents in making and implementing this plan. Incorrect Answers: A. The nurse should ask the parents if they would like to participate in providing care for their child. Active participation in the child's care promotes positive bereavement outcomes. B. The nurse should support the parents' and child's decisions and should allow the parents to participate in activities of their choosing (e.g. having multiple visitors, playing games, and going on family outings). If the child and parents choose a low-stimulation the nurse should ensure it is provided.

A nurse on a pediatric oncology unit is helping the parents of a child who is terminally ill to prepare for the impending loss of their child. Which of the following statements should the nurse make? A. "The nursing staff will bathe your child and take care of his daily needs." B. "Your child will be most comfortable in a low-stimulation environment." C. "Would you like assistance in planning where your child will die?" D. "Would you like hospice to continue providing curative care in your home?"

Correct Answer: D. A child who has pertussis ** The nurse should initiate droplet precautions for a child who has pertussis to decrease the risk of transmitting the infection to others on the unit. Pertussis, or whooping cough, is a bacterial infection that is transmitted via exposure or direct contact with the respiratory secretions from an infected person. Manifestations of pertussis include fever, sneezing, and a severe productive cough that generally becomes worse before getting better. Incorrect Answers A. Rocky Mountain spotted fever is a bacterial infection that is most commonly transmitted via a tick bite. Manifestations include fever, myalgia, and a maculopapular rash that primarily appears on the wrists and ankles. The rash can spread to the palms of the hands and the soles of the feet. The nurse should plan to use standard precautions when caring for a child who has Rocky Mountain spotted fever. B. Roseola is a viral infection classified within the herpes virus family. Primary manifestations are a rash and high fever. Other manifestations include lymphadenopathy, a sore throat, and a severe cough. The nurse should plan to use standard precautions when caring for a child who has roseola. C. Molluscum contagiosum is an infection caused by the poxvirus. Clinical manifestations include flesh-colored papules on the face, trunk, and extremities. Molluscum contagiosum is transmitted via direct skin-to-skin contact. Therefore, the nurse should initiate contact precautions when caring for a child who has Molluscum contagiosum.

A nurse on a pediatric unit has just received reports for 4 newly admitted clients. For which of the following children should the nurse plan to initiate droplet precautions? A. A child who has Rocky Mountain spotted fever B. A child who has roseola C.A child who has Molluscum contagiosum D. A child who has pertussis

Correct Answer: D. Ensure that staff visits with the child are kept short ** Children who have autism spectrum disorders have difficulty adjusting to new situations. The staff members should keep interactions with the child as brief as possible. Incorrect Answers: A. Children who have autism spectrum disorders have difficulty adjusting to new situations. The nurse should assign this child to a private room with decreased auditory and visual stimulation to assist the child's adaptation. B. Children who have autism spectrum disorders prefer minimal physical contact. The nurse should refrain from holding or restraining the child and should reduce eye contact as much as possible to prevent outbursts. C. Children who have autism spectrum disorders have difficulty redirecting their focus and changing activities. The nurse should clearly state expectations and instructions at the appropriate developmental level and should not provide choices about scheduling planned care.

A nurse on a pediatric unit is caring for a child who has autism spectrum disorder. Which of the following actions should the nurse take? A. Provide activities to stimulate the child's interest in the environment B. Make frequent eye contact when talking to the child C. Offer the child choices when scheduling planned care D. Ensure that staff visits with the child are kept short

Correct Answer: C. "Let your child eat with others when possible." ** Socialization with others promotes nutrition by making the child feel more comfortable in his surroundings and enhancing the enjoyment of meal times. Incorrect Answers: A. The child will be more likely to eat foods if he has participated in the menu selection. B. Highly seasoned foods and foods with strong odors are typically unappealing to clients who are not feeling well. The parents should offer foods that are familiar and do not have strong flavors or smells. D. Forcing the child to eat can result in rebellion, and the child might begin using food refusal as a control mechanism. Parents should instead offer meals and frequent snacks, make foods attractive and appealing, and praise the child when he does eat.

A nurse on a pediatric unit is caring for a child who is not eating well. Which of the following suggestions should the nurse offer to the parents to promote the child's food intake? A. "Make dietary selections for your child." B. "Offer foods that have strong flavors or smells." C. "Let your child eat with others when possible." D. "Make sure your child eats most of the food on his plate."

Correct Answer: A. Use role-play activities with the child ** Using role-play activities with the child will decrease the child's anxiety about the procedure. This will also provide an opportunity for the nurse to clarify any misconceptions the child might have about the procedure. Incorrect Answers: B. The nurse should avoid giving a detailed explanation of the procedure because this could increase the child's anxiety. The nurse should explain the procedure to the preschooler using simple words and phrases. C. To maintain the child's attention, the nurse should limit interactive sessions for a preschooler to 10 to 15 minutes each. D. The nurse should allow the child to see, hold, and ask questions about needleless IV supplies to familiarize the child with the potentially frightening aspects of the procedure, which will decrease the child's anxiety. Giving the child identical IV supplies to play with is a major safety risk because the child may be injured by the needle.

A nurse on a pediatric unit is caring for a preschooler who is prescribed an IV medication. Which of the following actions should the nurse take to prepare the child for the procedure? A. Use role-play activities with the child B. Provide the child with a detailed explanation of the procedure C. Implement interactive sessions of 30 min each with the child D. Give the child identical IV supplies to play with

Correct Answer: B. Allow the child to manipulate toy medical equipment ** A major function of play therapy is making potentially unmanageable situations manageable through symbolic representation, which provides children with opportunities to learn to cope. A preschooler does not have the language development to express fear of the unfamiliar medical equipment in the hospital. By encouraging the child to touch the equipment, the nurse is helping decrease the child's fear and intimidation in a safe environment using age-appropriate vocabulary. The use of toys enables children to transfer anxieties, fears, fantasies, and guilt to objects rather than people. Incorrect Answers: A. A child who fears hospitalization and surgery is likely to have nighttime awakenings and possibly night terrors. While the nurse can take actions to diminish a child's fears at night, this intervention does not address that particular problem. C. Play therapy differs from therapeutic play and allows a specially trained therapist to interpret the emotions of children who have mental health issues. D. Therapeutic play is a 1-on-1 activity between the nurse and the child.

A nurse on a pediatric unit is planning care for a preschooler who will be having a surgical procedure in the morning. The child has been crying despite his parents' presence at his bedside. The nurse should add engaging the child in therapeutic play to the care plan to offer which of the following benefits? A. Decrease the child's fear of the dark B. Allow the child to manipulate toy medical equipment C. Provide an opportunity to analyze the child's emotions D. Encourage parents to engage with their child

Correct Answer: A. Follow a nightly routine and established bedtime ** Preschool-age children test limits. A consistent approach to bedtime is important. Bedtime is more likely to be pleasant for everyone if a routine is established and followed every night. Incorrect Answers: B. Active play at bedtime is more likely to promote resistance to sleep rather than fatigue. C. This approach is likely to result in an overtired child who is awake and unpleasant. Children taught to maintain a bedtime routine at an early age will make the evening more pleasant for everyone, including themselves, and avoid sleep disturbances. D. A preschool-age child's bedtime routine should involve nightly oral care. Following this with a food treat is inappropriate.

A nurse teaching the parent of a 3-year-old toddler about promoting sleep. Which of the following pieces of information should the nurse include? A. Follow a nightly routine and established bedtime B. Encourage active play prior to bedtime C. Let the child remain awake until tired enough to go to sleep D. Reward the child with a food treat just before sleep if the child goes to bed on time

Correct Answer: C. Children who were born prematurely are more likely to be maltreated. ** Children who were born prematurely often require prolonged hospitalization after birth, which can interrupt the parent-child bonding that typically occurs in early infancy. Additionally, this group of children often have increased care needs, which increases the risk of caregiver fatigue and can lead to an increased potential for maltreatment. Incorrect Answers: A. While child maltreatment occurs in all age groups, infants from birth to 1 year of age have the highest rate of maltreatment. B. In single-parent families, the parent is more often the abuser than the nonbiological partner. D. While child maltreatment does occur across all socioeconomic groups, the most cases occur in families of lower income and education level. These families often have a greater number of additional stressors and restricted access to available support systems.

A charge nurse is providing education about child maltreatment to a group of newly licensed nurses. Which of the following pieces of information should the charge nurse include in the teaching? A. Preschoolers have the highest rates of maltreatment. B. In single-parent families, the parent's non-biological partner is typically the abuser of the child. c. Children who were born prematurely are more likely to be maltreated. D. Child maltreatment occurs equally across all socioeconomic groups.

Correct Answer: C. "A 6-year-old child should be able to count 13 coins." ** A 6-year-old child should be able to count 13 coins, identify morning and afternoon, and be able to identify right and left hands. Incorrect Answers: A. A 7-year-old child prefers playing with groups of friends of the same gender. B. A child who is 8 to 9 years old understands the concept of cause and effect. D. A child who is 10 to 12 years old should be able to wash his or her hair independently. An 8-year-old child should be able to brush his or her own hair,

A charge nurse is reviewing the expected growth and development of school-aged children with a group of staff nurses. Which of the following statements should the nurse include? A. "A 7-year-old child prefers to play with children of a different gender." B. "A 6-year-old child should understand the concept of cause and effect." C. "A 6-year-old child should be able to count 13 coins." D. "An 8-year-old child should be able to wash his or her own hair independently."

Correct Answer: C. A client who has diabetic ketoacidosis (DKA) and a blood glucose of 375 mg/dL ** The initial goal of therapy for DKA is a blood glucose level below 240 mg/dL. To accomplish this, the client should receive regular insulin via continuous IV infusion, and the nurse should monitor the blood glucose level hourly. The nurse should report this result so that the provider can adjust the client's insulin dosage. Incorrect Answers: A. An elevated WBC count is an expected finding with bacterial pneumonia. B. A low calcium level is an expected finding with chronic kidney disease. D. A decreased hematocrit is an expected finding with leukemia.

A charge nurse on a pediatric unit receives the laboratory results for several clients. Which of the following results should the nurse report to the provider? A. A client who has bacterial pneumonia and a WBC count of 15,800/mm^3 B. A client who has chronic kidney disease and a calcium level of 8.7 mg/dL. C. A client who has diabetic ketoacidosis (DKA) and a blood glucose of 375 mg/dL D. A client who has leukemia and a hematocrit of 32%

Correct Answer: D. "I will add rice cereal to my baby's feedings." ** The parent should add 1 tsp to 1 tbsp of rice cereal per ounce of formula or expressed breast milk to thicken the feedings and decrease the number of vomiting episodes. Incorrect Answers: A. The parent should give the medication to the infant 30 minutes before feeding because it is most effective during mealtime when the infant's plasma concentration is at its peak. B. The infant should be placed in an infant seat or at a 30° angle for 1 hour after feedings. C. The nurse should instruct the parent to avoid feedings just before bedtime.

A clinic nurse is providing teaching to the parent of a 1-month-old infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will give lansoprazole 30 min after my baby's feedings." B. "I will lay my baby on her side after feedings." C. "I will give my baby a bottle just before bedtime." D. "I will add rice cereal to my baby's feedings."

Correct Answer: B. Inspect the toddler's toys for sharp edges. ** The nurse should instruct the parents to inspect the toddler's toys for sharp edges or parts to decrease the risk of injury and bleeding to the toddler. Incorrect Answers: A. The nurse should not instruct the parents to administer aspirin or medications that contain aspirin, as this could increase the toddler's risk of bleeding. C. The nurse should instruct the parents to elevate and rest the toddler's affected joint during a bleeding episode. D. The risk of infection is a concern for a toddler who has an immunodeficiency disorder, not hemophilia.

A home health nurse is developing a plan of care a toddler who has hemophilia. Which of the following instructions for the parents should the nurse include in the plan? A. Administer low-dose aspirin for pain. B. Inspect the toddler's toys for sharp edges. C. Perform passive range-of-motion of the affected joint during a bleeding episode. D. Avoid contact with people who have respiratory infections.

Correct Answer: A. Toddlers will react to the parents' anxiety and sadness. ** The nurse should identify that toddlers have little understanding of death. Their reaction is related to changes in routine and the parents' emotions. Incorrect Answers: B. Preschoolers might perceive death as punishment for bad behavior. C. A recognition of the permanence of death is often not achieved until age 9 or 10. D. A realistic concept of death is often not achieved until age 9 or 10.

A hospice nurse is conducting a support group for parents of toddlers who have a terminal illness. Which of the following pieces of information should the nurse include in the teaching? A. Toddlers will react to the parents' anxiety and sadness. B. Toddlers view death as punishment for bad behavior. C. Toddlers view death as permanent and irreversible. D. Toddlers have a realistic concept of death.

Correct Answer: A. Diphtheria, tetanus, and pertussis (DTAP) ** Children should receive booster doses of the DTAP immunization between the ages of 4 and 6. Around this age, blood titers drop due to decreasing antibodies. Incorrect Answers: B. Infants should receive the PCV immunization at 2 months, 4 months, and 6 months, as well as the fourth dose between 12 and 18 months. C. Infants should receive the Hib immunization at 2 months, 4 months, and 6 months, as well as the fourth dose between 12 and 18 months. D. The infant should receive the Hep B immunization at birth, 1 to 2 months, and 6 to 18 months.

A nurse at a clinic is preparing to administer immunizations to a 5-year-old child. Which of the following immunizations should the nurse plan to give? A. Diphtheria, tetanus, and pertussis (DTAP) B. Pneumococcal (PCV) C. Haemophilus influenzae type B (Hib) D. Hepatitis B (Hep B)

Correct Answer: C. Toddlers can be given up to 120-180 ml (4-6 oz) of juice per day. ** Parents should limit a toddler's juice intake to 120 to 180 ml per day because juice is high in sugar and should not replace more important nutrients. Incorrect Answers: A. Infants and toddlers should avoid low-calorie milk because the dietary fat in milk is essential for growth and development. B. Preschoolers need 13 to 19 g of protein per day to support growth and development. D. School-age children usually prefer afternoon snacks but should be encouraged to make healthy food choices.

A nurse at a community health department is discussing the nutritional needs of children with a group of parents and guardians. Which of the following pieces of information should the nurse include? A. Infants should be transitioned to low-calorie milk at 12 months. B. Preschoolers need 10-12 g of protein per day. C. Toddlers can be given up to 120-180 mL (4-6 oz) of juice per day. D. School-age children should be encouraged to avoid afternoon snacks.

Correct Answer: A. Head lagging when the infant is pulled from a lying to a sitting position ** At the age of 5 months, the infant should have no head lag when pulled to a sitting position; therefore, the nurse should report this finding to the provider. Incorrect Answers: B. The startle reflex disappears by the age of 4 months, and the crawl reflex disappears around the age of 6 weeks. C. At the age of 5 months, the infant can visually follow a dropped object but is unable to pick up the object until around the age of 6 months. D. The infant should be able to roll from back to side at the age of 4 months.

A nurse at a pediatric clinic is assessing a 5-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider? A. Head lagging when the infant is pulled from a lying to a sitting position B. Absence of startle and crawl reflexes C. Inability to pick up a rattle after dropping it D. Rolling from back to side

Correct Answer: B. Minimize physical contact with the child initially ** The nurse should initially minimize physical contact with the toddler and progress from the least traumatic to the most traumatic procedures. Incorrect Answers: A. The nurse should start with the least invasive interventions and proceed to the more invasive. The head-to-toe approach is recommended for preschool-age and older children. C. The nurse should describe procedures using age-appropriate language the child can understand. D. If the child becomes uncooperative, the nurse should perform the procedures more quickly.

A nurse in a pediatric clinic is assessing a toddler at a well-child visit. Which of the following actions should the nurse take? A. Perform the assessment in a head-to-toe sequence B. Minimize physical contact with the child initially C. Explain procedures using medical terminology D. Stop the assessment if the child becomes uncooperative

Correct Answer: D. Ensure the child's dietary intake of calcium and iron is adequate ** A child who has an elevated blood lead level should have an adequate intake of calcium and iron to reduce the absorption of and effects from the lead. Dietary recommendations should include milk as a good source of calcium. Incorrect Answers: A. Vitamin C does not influence absorption or excretion of lead, and intake does not need to be reduced for a child who has a blood lead level of 3 mcg/dL. Over time, a reduced intake can result in a vitamin C deficiency. B. A 3-year-old child does not need a folic acid supplement. This will not influence absorption or excretion of lead. C. Pancreatic enzymes are administered to children who have cystic fibrosis, not an elevated blood lead level.

A nurse in a pediatric clinic is caring for a 3-year-old child who has a blood lead level of 3 mcg/dL. When teaching the toddler's parent about the correlation of nutrition with lead poisoning, which of the following pieces of information is appropriate for the nurse to include? A. Decrease the child's vitamin C intake until the blood lead level decreases to zero B. Administer a folic acid supplement to the child each day C. Give pancreatic enzymes to the child with meals and snacks D. Ensure the child's dietary intake of calcium and iron is adequate

Correct Answer: A. Slices of ripe banana ** Toddlers should have about 8 oz (1 cup) of fruit per day. Bananas are nutritious and, as long as they are soft, do not present a choking hazard for young children. Incorrect Answers: B. Popcorn, chunks of cheese, and raisins present choking hazards for young children. C. Hot dogs, sausages, and tough meat present choking hazards for young children. D. Raw carrots, nuts, and seeds present choking hazards for young children.

A nurse in a pediatric clinic is talking with the parent of a toddler who states that her child will not sit at the table to eat with the family. She asks the nurse for recommendations for "finger foods" for her child. Which of the following foods should the nurse suggest? A. Slices of ripe banana B. Popcorn C. Slices of hot dogs D. Raw carrots

Correct Answer: B. Healthy weight ** Body mass index (BMI) is a measure of an individual's weight relative to height. A BMI from 18.5 to 24.9 is in the healthy range. Therefore, this client's weight is considered healthy. Incorrect Answers: A. A BMI below 18.5 is considered underweight and a health risk. C. A BMI from 25 to 29.9 is in the overweight range. D. A BMI greater than or equal to 30 is in the obese range.

A nurse in a provider's office is assessing a client. The nurse determines the client's body mass index is 21.2. This finding is classified as which of the following? A. Underweight B. Healthy weight c.Overweight D. ObesE

Correct Answer: A. Tell the guardian that a repeat dose of medication should not be given ** The greatest risk to this infant is an injury from digoxin toxicity. Therefore, the priority action for the nurse to take is to instruct the guardian not to administer another dose of medication. The nurse should follow-up with the guardian frequently to determine if the child has further episodes of vomiting. If so, the nurse should notify the provider immediately because vomiting is a possible indication of digoxin toxicity. Incorrect Answers: B. The nurse should verify the prescribed digoxin regimen and the accuracy of home administration, However, there is another action the nurse should take first. C. The nurse should attempt to identify possible causes of the infant's vomiting. However, there is another action the nurse should take first. D. The nurse should determine if the infant's urinary output is adequate to evaluate the effectiveness of the digoxin in managing the infant's heart failure. However, there is another action the nurse should take first.

A nurse in a provider's office receives a phone call from the guardian of an infant who just vomited after the administration of digoxin. Which of the following actions should the nurse take first? A. Tell the guardian that a repeat dose of medication should not be given B. Verify the prescribed medication regimen C. Determine if the infant has been exposed to others who are ill D. Ask the guardian about the infant's urinary output

Correct Answer: B. The child is withdrawn and refuses to talk. ** Separation anxiety manifests in 3 stages: protest, despair, and detachment. Withdrawal and lack of communication are manifestations of the stage of despair. Incorrect Answers: A. Physical attacks are a manifestation of the stage of protest. C. Attempts to run away to find her parents is a manifestation of the stage of protest. D. Screaming and loud crying are manifestations of the stage of protest.

A nurse in an acute pediatric unit is caring for a 2-year-old child who has separation anxiety when her parents to leave for work. The nurse should identify which of the following behaviors as a manifestation of the stage of despair? A. The child tries to bite the nurse. B. The child is withdrawn and refuses to talk. C. The child attempts to run away to find her parents. D. The child screams and cries loudly.

Correct Answer: D. Chronic diarrhea ** Chronic diarrhea is an expected finding for a preschooler who has HIV. Incorrect Answers: A. Generalized petechiae are not a manifestation of HIV in a preschooler. B. Jaundice is not a manifestation of HIV in a preschooler. C. Failure to thrive and weight loss are expected findings for a preschooler who has HIV.

A nurse is assessing a preschooler who has HIV. Which of the following manifestations should the nurse expect? A. Generalized petechiae B. Jaundice C. Obesity D. Chronic diarrhea

Correct Answer: D. 1/2 cup of peanut butter with apple slices ** Peanut butter and apple slices have a total of 28.91 g of protein. This is a good choice for this client because peanut butter is high in protein, which promotes the healing process. Incorrect Answers: A. A medium baked potato has 4.32 g of protein. B. A wheat bagel with 1 tbsp of apricot jam has 10.14g of protein. C. One large orange has 1.06 g of protein.

A nurse is caring for a child who adheres to a vegetarian diet and has sustained superficial partial-thickness burns. The nurse should recommend which of the following food choices due to the high protein content? A. Medium baked potato B. Wheat bagel with 1 tbsp of apricot jam C. Large orange D. 1/2 cup of peanut butter with apple slices

Correct Answer: A. "An abdominal ultrasound will confirm the pocket in the intestine." ** Intussusception is the invasion of a part of the intestine into another, creating a pocket. The presence of an intussusception is confirmed by an abdominal X-ray, ultrasound, or CT scan. Incorrect Answers: B. Genotyping is performed to determine a child's gene composition and is used for hereditary disease identification. C. A biopsy is done to identify a defect of nerve innervation in the colon and is used for the diagnosis of Hirschsprung's disease. D. An upper gastrointestinal series focuses on an area that is too high to allow visualization of an intussusception and is used diagnosis of pyloric stenosis.

A nurse is caring for a child who has a possible intussusception. The parents of the child ask the nurse how the diagnosis is determined. Which of the following responses should the nurse make? A. "An abdominal ultrasound will confirm the pocket in the intestine." B. "Genotyping will be done to identify this condition." C. "A biopsy will be done on a small amount of tissue from the colon." D. "An upper GI series should identify the area involved."

Correct Answer: D. Hematuria ** Hematuria can be detected visually in clients who have acute post-streptococcal glomerulonephritis. Incorrect Answers: A. Elevated blood pressure is a manifestation of acute post-streptococcal glomerulonephritis. B. Serum lipid levels are not elevated for clients who have acute post-streptococcal glomerulonephritis. The levels are within the expected reference range. C. Serum potassium levels are within the normal expected reference range or elevated for clients who have acute post-streptococcal glomerulonephritis.

A nurse is caring for a school-aged child who has acute post-streptococcal glomerulonephritis. Which of the following manifestations should the nurse expect? A. Hypotension B. Elevated serum lipid levels C. Decreased serum potassium levels D. Hematuria

Correct Answer: D. Dry mucous membranes ** Dry mucous membranes are an expected finding of moderate dehydration. Incorrect Answers: A. Absent tears is an expected finding of severe dehydration. B. A weight loss of >10% is an expected finding of severe dehydration. C. Lethargy is an expected finding of severe dehydration.

A nurse is caring for an infant who is 6 months old and has moderate dehydration. Which of the following findings should the nurse expect? A. Absent tears B. Weight loss>10% C. Lethargy D. Dry mucous membranes

Correct Answer: A. People can come back to life after they die. ** A preschooler typically views death as temporary and interchangeable with life. Incorrect Answers: B. An understanding that death is inevitable is usually not achieved until age 9 to 10. C. School-age children might view death as a monster. D. Toddlers are typically unable to comprehend the meaning of death; however, a preschooler has usually moved beyond this level of egocentricity.

A nurse is caring for the family of a preschooler who has a terminal illness. The nurse should teach the family to expect the preschooler to have which of the following concepts of death? A. People can come back to life after they die. B. Death eventually occurs for all people. C. Death is a scary monster that causes people to die. D. People are unable to be anything but alive.

Correct Answer: A. "Put your shoes on." ** Children should be able to pull on their shoes when they are 3 years old. They typically cannot tie their shoes until they are 5 years of age. Incorrect Answers: B. A child is typically not able to memorize time-associated words until the age of 5. C. A child is typically not able to effectively use scissors until the age of 4. D. A child is typically not able to complete this task before the age of 5.

A nurse is performing a developmental assessment on a 3-year-old child. Which of the following commands should the nurse expect the child to complete successfully? A. "Put your shoes on." B. "Name the days of the week." C. "Cut out this picture with a pair of scissors." D. "Balance on 1 foot with your eyes closed."

Correct Answer: B. Lay the preschooler on the nonoperative side The preschooler should not be positioned on the shunt side postoperatively to avoid putting pressure on the shunt or surgical site. Incorrect Answers: A. The nurse should monitor the child's pupillary response every 15 to 30 minutes immediately following neurological surgery. Increased intracranial pressure can put pressure on the oculomotor nerve, causing unilateral pupil dilation. C. The nurse should maintain the preschooler in a flat position to avoid rapid draining of intracranial fluid through the shunt. D. The nurse should check the preschooler's bowel sounds frequently because peritonitis or an ileus can be postoperative complications.

A nurse is planning care for a preschooler who is immediately postoperative following the placement of a ventriculoperitoneal shunt. Which of the following interventions should the nurse include in the plan? A. Monitor the preschooler's pupils every 8 hours B. Lay the preschooler on the nonoperative side C. Keep the head of the bed elevated to 30° D. Check bowel sounds once per day

Correct Answer: A. Encourage the preschooler to bring a favorite toy to the hospital ** The nurse should encourage the preschooler to bring a favorite toy or blanket to the hospital on the day of the procedure. A familiar object provides comfort and relieves fear. Incorrect Answers: B. The nurse should identify that a preschooler has an attention span of approximately 5 minutes. Therefore, the nurse should plan the teaching session to be short and use simple words. C. The nurse should schedule the preoperative teaching session for 3 to 4 days prior to the procedure to allow the preschooler and the family time to prepare for hospitalization. D. The nurse should not falsely reassure the preschooler that pain will not occur following the procedure. Instead, the nurse should discuss postoperative pain and pain medication in simple terms.

A nurse is planning preoperative teaching for a preschooler who is scheduled for a tonsillectomy. Which of the following interventions should the nurse plan to Questic include? A. Encourage the preschooler to bring a favorite toy to the hospital B. Spend 30 minutes teaching the preschooler about what to expect C. Schedule the teaching session for the morning of the preschooler's procedure D. Reassure the preschooler that medicine will prevent pain after the procedure

Correct Answer: A. The child prefers to sit on the parent's lap during the examination ** Toddlers and infants who are able to sit typically prefer to sit in their parents' lap throughout the examination. Incorrect Answers: B. Preschool and school-aged children are typically interested in a demonstration of how the examination equipment works. Toddlers might want to inspect the equipment before use but are not usually interested in how it functions. C. School-aged children are typically interested in how the body works and are open to instructions. Toddlers can understand the names and basic actions that body parts can perform, but they do not usually ask specific questions about body functions. D. Adolescents are typically concerned about comparing their development to the development of peers. Toddlers are just beginning to understand their existence as a separate person from their mother and are not concerned with how their development compares to other toddlers.

A nurse is preparing to assess a 2-year-old toddler. Which of the following behaviors should the nurse expect during the examination? A. The child prefers to sit on the parent's lap during the examination B. The child is interested in how the examination equipment works C. The child asks specific questions about body functions D. The child questions how her development compares to other children at the same age

Correct Answer: A. The infant looks at his hands ** Infants usually start to look at their hands while lying down or sitting between 12 to 20 weeks of age. Convergence on near objects is usually well established by 3 months of age. Incorrect Answers: B. By 3 months of age, infants' hands should be mostly open, and they usually hold onto objects placed into their hands. Voluntary grasping of objects does not usually occur until 5 months of age. A crude pincer grasp usually develops by 8 to 9 months of age. C. Infants usually have a partial to slight head lag when pulled to a sitting position at 3 months. By 4 to 6 months, infants gain full head control. D. While some infants might independently roll from their back to their abdomen earlier than expected, a nurse would not expect an infant to be able to do this until 6 months of age.

A nurse is preparing to assess a 3-month-old infant during a well-child visit. Which of the following observations should the nurse expect? A. The infant looks at his hands B. The infant has a pincer grasp C. The infant has no head lag when pulled to a sitting position D. The infant can independently roll from his back to his abdomen

Correct Answer: D. "I will turn my child onto her side when a seizure begins." ** To reduce the risk of aspiration and to improve oxygenation, the guardian should place the child in a side-lying position. Incorrect Answers: A. The guardian should notify emergency services if the child has a seizure that lasts more than 5 minutes. B. The guardian should not offer the child anything to drink or eat during the postictal phase because the child's gag and swallow reflex might be dulled or absent. C. The guardian should not hold or attempt to restrain the child during a seizure because this could injure the child.

A nurse is providing teaching about home care to the guardian of a school-aged child who has seizures. Which of the following statements by the guardian indicates an understanding of the teaching? A. "I will call an ambulance if my child's seizure lasts more than 10 minutes." B. "I will offer my child clear liquids immediately following a seizure." C. "I will tightly hold my child to restrain her during a seizure." D. "I will turn my child onto her side when a seizure begins."

Correct Answer: B. "The pneumococcal and influenza vaccines are recommended for your child." ** Immunization against common childhood illnesses, including influenza and pneumococcal disease, is recommended for all children exposed to and infected with HIV. Incorrect Answers: A. Half doses of immunizations do not provide the immunity necessary to protect the child from common childhood illnesses. C. Delaying immunizations places the child at risk of contracting an illness. D. Immunizations do not need to be restarted once the client is no longer immunocompromised.

A nurse is providing teaching about immunizations to the parents of a severely immunocompromised child who has human immunodeficiency virus (HIV). Which of the following statements should the nurse include in the teaching? A. "Your child's immunizations today will be half-doses." B. "The pneumococcal and influenza vaccines are recommended for your child." C. "Immunizations will be delayed until your child tests HIV-negative." D. "Your child will need to restart the immunization schedule once your child's laboratory values are within the reference range."

Correct Answer: A. Place a plastic bag over the cast when showering ** The nurse should instruct the adolescent to keep the cast dry by placing a plastic bag over it while showering. Incorrect Answers: B. Placing any instruments inside the cast can injure the skin and cause an infection. C. The fingers should be moved and exercised every 4 hours for the first 24 hours. D. Fiberglass cast material is porous; therefore, magic markers should not be used to draw on or autograph the cast.

A nurse is providing teaching to an adolescent who has a fiberglass arm cast. Which of the following instructions should the nurse include in the teaching? A. Place a plastic bag over the cast when showering B. Insert a dull knitting needle into the cast to rub itchy skin C. Exercise fingers every 8 hr for the first 24 hr D. Draw on the cast using magic markers

Correct Answer: A. Bulky stools ** The nurse should identify that bulky stools can cause a child who has cystic fibrosis to develop a prolapsed rectum. The nurse should implement interventions to help decrease the bulk of the child's stools. Incorrect Answers: B. The nurse should identify that a weakened rectal sphincter is not a manifestation of cystic fibrosis. C. The nurse should identify that a prolapsed rectum is associated with insufficient pancreatic enzymes. D. The nurse should identify that a prolapsed rectum is associated with increased intra-abdominal pressure.

A nurse is providing teaching to the parent of a child who has cystic fibrosis and a prolapsed rectum. The nurse should identify that which of the following is a cause of this complication? A. Bulky stools B. Weakened rectal sphincter C. Elevated pancreatic enzymes D. Decreased intra-abdominal pressure

Correct Answer: B. Dry clothing in a hot dryer for at least 20 min ** The nurse should instruct the parent to dry the child's clothing in a hot dryer for at least 20 minutes. Incorrect Answers: A. The nurse should instruct the parent to machine-wash the child's clothing and bed linens in hot water. C. The nurse should instruct the parent to soak the child's combs and brushes for 10 minutes in boiling water. D. The nurse should instruct the parent to seal the child's nonwashable items in a bag for 14 days.

A nurse is providing teaching to the parent of a school-aged child who has pediculosis. Which of the following instructions should the nurse include? A. Machine-wash clothing in cold water B. Dry clothing in a hot dryer for at least 20 min c. Soak combs and brushes for 5 min in boiling water D. Seal nonwashable items in a bag for 7 days

Correct Answer: D. At 4 to 6 months of age ** The nurse should identify that infants are developmentally ready for solid foods at 4 to 6 months of age. Incorrect Answers: A. The disappearance of the extrusion reflex, rather than the rooting reflex, is an indicator of the infant's developmental readiness for solid • foods. B. Infants between 2 and 3 months of age still have the extrusion reflex and are not developmentally ready for solid foods. C. The timing of the eruption of the infant's first tooth varies greatly and tis not an appropriate indicator for introducing solid foods.

A nurse is providing teaching to the parents of an infant who is breastfeeding. When should the nurse instruct the parents to introduce solid foods in the infant's diet? A. After the rooting reflex disappears B. At 2 to 3 months of age C. After the infant's first tooth erupts D. At 4 to 6 months of age

Correct Answer: A. Hydrocephalus ** In the surgical repair of the myelomeningocele, the pathway for the cerebral spinal fluid is altered. Therefore, the infant is at risk of hydrocephalus, and the nurse should monitor the infant for this condition. Incorrect Answers: B. Congenital hypotonia is a paralytic form of spinal muscular atrophy that is characterized by progressive weakness and wasting of skeletal muscles; therefore, the infant should not be monitored for this complication. C. Otitis media results from blocked eustachian tubes and is not related to neural tube defects; therefore, the infant should not be monitored for this condition. D. Osteomyelitis results from an organism gaining access to the bone; therefore, the infant should not be monitored for this condition.

A nurse is teaching a newly hired nurse about caring for an infant who is postoperative following myelomeningocele repair. The nurse should teach the newly hired nurse to monitor the infant for which of the following complications? A. Hydrocephalus B. Congenital hypotonia c. Otitis media D. Osteomyelitis

Correct Answer: D. "Your child should be able to scribble spontaneously using a crayon at 15 months of age." ** At the age of 15 months, the toddler should be able to scribble spontaneously. At the age of 18 months, the toddler should be able to make strokes imitatively. Incorrect Answers: A. A toddler's use of the appropriate pronoun when referring to self does not occur until 30 months of age. B. A toddler develops an intense focus and interest in pictures at 15 months of age. C. Most toddlers maintain bowel and bladder control during the daytime by 30 months of age. The nurse should teach the parent not to expect the toddler to accomplish this task by the age of 24 months.

A nurse is teaching a parent of a 12-month-old infant about development during the toddler years. Which of the following statements should the nurse include? A. "Your child should be referring to himself using the appropriate pronoun by 18 months of age." B. "A toddler first shows interest in looking at pictures at 20 months of age." C. "A toddler should have daytime control of his bowel and bladder by 24 months of age." D. "Your child should be able scribble spontaneously using a crayon at 15 months of age."

Correct Answer: A. They provide direct stimulation of auditory nerve fiber. ** Cochlear implants work by directly stimulating nerve fibers in the cochlea. Incorrect Answers: B. Bone conduction hearing aids, not cochlear implants, conduct sound waves through the skull to the inner ear. C. Some hearing aids use digital sound processing to help clients who have high-frequency hearing loss, but cochlear implants do not. D. An implantable piezoelectric device converts vibrations in the eardrum and ossicles to signals that are amplified by a sound processor. A driver transmits them to the inner ear for sound perception.

A nurse is teaching the parents of an infant about treatment options for profound sensorineural hearing loss. The nurse should include which of the following pieces of information about the function of cochlear implants? A. They provide direct stimulation of auditory nerve fiber. B. They conduct sound waves through the mastoid bone to the cochlea. C. They process digital sound to amplify several sound frequencies. D. They convert vibrations in the ear's structures to electrical signals.

Correct Answer: B. Massage the anterior area of the infant's ear following administration ** The nurse should instruct the parents to massage the anterior area of the ear following the administration of eardrops to facilitate instillation of the medication. Incorrect Answers: A. Otic solution should be warm or room temperature before instilling it in the infant's ear. C. Hyperextending the neck is for nasal medication administration rather than otic medication administration. D. The nurse should instruct the parents to pull the auricle up and back for children older than 3 years of age and downward and straight back for children younger than 3 years of age.

A nurse is teaching the parents of an infant who has acute otitis media about how to administer antibiotic eardrops. Which of the following instructions should the nurse include? A. Chill the medication prior to administration B. Massage the anterior area of the infant's ear following administration C. Hyperextend the infant's neck during administration D. Pull the auricle up and back during medication administration

Correct Answer: B. Frequent hospitalizations ** Children who experience multiple and frequent hospitalizations are at an increased risk for stress-related reactions to hospitalization. Incorrect Answers: A. Children between the ages of 6 months and 5 years are more vulnerable to the stress of hospitalization than a 10-year-old child. C. A child's stress and anxiety with hospitalization are reduced when parents are highly involved with their children and have close bonds. Children who are hospitalized are at risk for increased stress if there is a lack of cohesion between the parent and the child. D. Children who demonstrate irritable and difficult temperaments are at increased risk of stress-related reactions to hospitalization.

A nurse on a pediatric unit is reviewing the health record of a child who is demonstrating increasing levels of stress after admission. The nurse should identify which of the following findings as a risk factor for a stress-related reaction to hospitalization? A. Age 10 years B. Frequent hospitalizations C. Parent bonding with child D. Calm, quiet demeanor

Correct Answer: A. Galactosemia ** An infant who has galactosemia cannot metabolize lactose. Breast milk contains lactose, which can cause failure to thrive, cirrhosis, developmental delays, and even death in affected infants. An infant who has galactosemia is fed with formula made with milk substitutes. Incorrect Answers: B. An infant who has hyperbilirubinemia can develop jaundice due to the accumulation of bilirubin in the system. Breastfeeding is encouraged in the early postpartum period for infants who develop hyperbilirubinemia because the colostrum in breast milk is a natural laxative that promotes the excretion of excess bilirubin. C. Glycogen storage disease is a congenital disorder in which glycogen, which is usually stored in the liver and metabolized into glucose when needed, cannot be metabolized into glucose due to a missing or deficient enzyme. As a result, the infant develops hypoglycemia and can experience neurological damage. Treatment involves continuous nasogastric or gastrostomy feedings during the night. However, breastfeeding is not contraindicated for infants who have glycogen storage disease. D. Infants who are born with congenital hypothyroidism will require lifelong treatment with a thyroid-replacement medication. However, breastfeeding is not contraindicated for infants who have hypothyroidism.

A nurse working on a maternal-newborn unit is teaching a group of newly licensed nurses about assisting new mothers with breastfeeding. The nurse should include which of the following infant conditions as a contraindication for breastfeeding? A. Galactosemia B. Hyperbilirubinemia C. Glycogen storage disease D. Hypothyroidism

Correct Answers: B. Nausea D. Urticaria E. Stridor ** A common gastrointestinal response to excessive histamine release is nausea. A common skin manifestation of excessive histamine release is hives, also known as urticaria. A serious, life-threatening response to excessive histamine release is airway narrowing, which presents as dyspnea and stridor. Incorrect Answers: A. Histamine is a potent vasodilator; therefore, a client who is going into anaphylaxis will exhibit tachycardia. C. Histamine is a potent vasodilator, so the child will exhibit hypotension.

A school nurse is assessing a child who has been stung by a bee. The child's hand is swelling, and the nurse notes that the child is allergic to insect stings. Which of the following findings should the nurse expect if the child develops anaphylaxis? (Select all that apply.) A. Bradycardia B. Nausea C. Hypertension D. Urticaria E. Stridor

Correct Answer: C. Provide the toddler with a favorite stuffed animal at bedtime. ** Providing the toddler with a favorite soft toy at bedtime can help the toddler feel more secure and facilitate sleep. Incorrect Answers: A. A consistent bedtime routine is helpful in promoting sleep for a toddler. B. Watching television before bedtime can stimulate the toddler and cause sleep disturbances. D. Activity should be decreased prior to bedtime to facilitate sleep because increased activity can stimulate the toddler and cause sleep disturbances.

During a well-child visit, the guardian of a toddler reports that the toddler takes several hours to fall asleep at night. Which of the following recommendations should the nurse make? A. Vary the time the toddler goes to bed each night. B. Allow the toddler to watch television before bedtime. C. Provide the toddler with a favorite stuffed animal at bedtime. D. Increase the toddler's activity

Correct Answer: B. Use an oral syringe to place the medication alongside the infant's tongue **The nurse should use an oral syringe to administer the medication slowly alongside the infant's tongue or at the side of the mouth. The nurse should give the child time to swallow between deposits. Incorrect Answers: A. Infants should not be given honey due to the risk of exposure to botulism spores. The nurse can use other foods like pudding or jam to alter the taste of the medication. C. The might refuse the formula due to an altered taste from the medication. Additionally, if the infant does not drink the entire bottle, incomplete dosing of the medication can occur. D. The nurse should administer the medication while holding the infant firmly in a semi-reclining position. Administering the medication with the infant in a supine position can result in aspiration.

The nurse is preparing to administer an oral medication to an 8-month-old infant. Which of the following actions should the nurse take? A. Mix the medication with 1 tsp of honey to sweeten the taste for the infant B. Use an oral syringe to place the medication alongside the infant's tongue C. Add the medication to the infant's bottle of formula D. Place the infant in a supine position to administer the medication

Correct Answer: B. Toddlers ** Toddlers demonstrate parallel play. Incorrect Answers: A. Infants demonstrate solitary play. C. Preschoolers demonstrate associative play. D. School-age children demonstrate cooperative play.

A nurse in a provider's office is observing children playing in the waiting room. The nurse should expect to identify parallel behavior in which of the following age groups? A. Infants B. Toddlers C. Preschoolers D. School-age children

Correct Answer: B. Enlarged lymph nodes ** Manifestations of stage I Hodgkin disease include painless enlargement of lymph nodes. Incorrect Answers: A. Generalized petechiae are not a manifestation of Hodgkin disease. C. Chronic vomiting is not a manifestation of Hodgkin disease. D. Dependent edema is not a manifestation of Hodgkin disease.

A nurse is assessing a child who has stage I Hodgkin disease. Which of the following findings should the nurse expect? A. Generalized petechiae B. Enlarged lymph nodes c. Chronic vomiting D. Dependent edema

Correct Answer: D. Supine ** The client should be placed in the supine position, with the legs in a frog position. Incorrect Answers: A. The side-lying position may be used during a lumbar puncture. B. A semi-recumbent position is used when performing a gavage feeding. The client's head and chest should be elevated. C. The flexed sitting position may be used during a lumbar puncture.

A nurse is assisting a provider during a femoral venipuncture on a toddler. The nurse should place the child in which of the following positions? A. Side-lying B. Semi-recumbent C. Flexed sitting D. Supine

Correct Answer: A. Celiac disease ** The nurse should recognize that celiac disease causes chronic diarrhea due to malabsorption. Other malabsorption conditions include short- bowel syndrome, lactose intolerance, and congenital enzyme deficiency. Incorrect Answers: B. Ulcerative colitis causes chronic diarrhea because it is an inflammatory bowel disease. C. Hirschsprung's disease causes chronic diarrhea because of motility disorders. D. Crohn's disease causes chronic diarrhea because it is an inflammatory bowel disease.

A nurse is discussing the causes of chronic diarrhea with a client. Which of the following conditions is caused by malabsorption? A. Celiac disease B. Ulcerative colitis C. Hirschsprung's disease D. Crohn's disease

Correct Answer: D. Rock the child using long, rhythmic movements ** The nurse can implement relaxation strategies by sitting with the child in a well-supported position such as against the chest and rocking or swaying back and forth in long, wide movements. Incorrect Answers: A. This is an example of a distraction strategy. B. This is an example of guided imagery. C. Evidence-based practice indicates that bouncing is not an appropriate action.

A nurse is planning to implement relaxation strategies with a young child prior to a painful procedure. Which of the following actions should the nurse take? A. Ask the child to hold a breath and blow it out slowly B. Ask the child to describe a pleasurable event C. Bounce the child gently while holding him upright D. Rock the child using long, rhythmic movements

Correct Answer: 7.5

A nurse is preparing to administer acetaminophen 240 mg PO daily to a child who has a temperature of 38.9°C (102°F). The amount available is acetaminophen oral solution 160 mg/5 mL. How many ml should the nurse administer dose? (Fill in the blank with the numeric value only, round the answer to the nearest tenth, and use a leading zero if applicable. Do not use a trailing zero.)

Correct Answer: B. "I will administer the iron tablet with orange juice." ** The intake of citrus juice with the iron will increase the iron's absorption. Incorrect Answers: A. The parent should spread the iron doses throughout the day to prevent gastric upset. C. Antacids decrease the absorption of iron. D. Crushing the tablet interferes with absorption and distribution.

A nurse is teaching the parents of a 10-year-old child who has iron-deficiency anemia. Which of the following statements by a parent indicates an understanding of the teaching? A. "I will give my child an iron tablet once each day at bedtime." B. "I will administer the iron tablet with orange juice." c. "I will encourage my child to take an antacid with the iron tablet." D. "I will crush the iron tablet prior to giving it to my child."

Correct Answer: B. Plastic stethoscope ** Preschool play centers on imitative activities. Providing a stethoscope allows the child to engage in therapeutic play. Imitating health care personnel may ease the child's fear of unfamiliar equipment. Incorrect Answers: A. A brightly colored mobile is appropriate for a young infant but does not meet the activity needs of a preschool-age child. C. A small-piece jigsaw puzzle is too difficult for most preschool-age children and can frustrate them rather than entertain them. D. A 4-year-old child is not able to read independently. The nurse should provide a picture book instead.

A nurse on a pediatric unit is admitting a 4-year-old child. Which of the following toys should the nurse plan to provide for the child to engage in independent play? A. Brightly colored mobile B. Plastic stethoscope C. Small-piece jigsaw puzzle D. Book of short stories

Correct Answer: A. The infant's mother is likely HIV positive. ** Transmission of HIV from a woman to her infant can occur during pregnancy, in delivery, or through breastfeeding. Although it is possible for the infant to acquire HIV from sexual abuse, mother-to-child transmission accounts for the majority of HIV/AIDS cases in infants. Incorrect Answers: B. The ELISA test is unreliable for HIV testing in infants under 18 months of age because of false-positive results due to maternal antibodies. The results are reliable, however, for clients 18 months of age and older. C. While antiretroviral medications cannot cure HIV, they do slow the progress of the infection for clients of all ages. D. Infants who are HIV positive should receive immunization against childhood illnesses, including measles, mumps, rubella, and influenza.

An 18-month-old infant has Pneumocystis carinii pneumonia. Results of enzyme-linked immunosorbent assay (ELISA) testing indicate that she is HIV positive. When planning care, the nurse should consider which of the following factors? A. The infant's mother is likely HIV positive. B. The infant's ELISA test result is probably a false positive for HIV. C. Antiretroviral medications are inappropriate for infants and children who have HIV. D. HIV-positive status is a contraindication for measles, mumps, and rubella immunizations.

Correct Answer: A. "I should ignore the stuttering and not interrupt her." ** Stuttering is an expected part of speech development in the preschool years. As language skills improve, stuttering typically ceases by 5 years of age. Parents should be instructed not to focus on the stuttering so the behavior is not reinforced and does not become prolonged.

The nurse is providing teaching to the parent of a 4-year-old child who stutters. Which of the following statements by the parent indicates an understanding of the teaching? A. "I should ignore the stuttering and not interrupt her." B. "I should finish my child's sentence if she is stuck on a word." C. "I should reward my child when she doesn't stutter." D. "I should tell my child to slow down when she starts stuttering."